Provider Demographics
NPI:1174071534
Name:LAGUNA EARLY CHILDHOOD PROGRAM
Entity type:Organization
Organization Name:LAGUNA EARLY CHILDHOOD PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR DIVISION OF EARLY CHILDHOO
Authorized Official - Prefix:
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-552-1013
Mailing Address - Street 1:P.O. BOX 207
Mailing Address - Street 2:1-40 W EXIT 114 BLDG 1125
Mailing Address - City:LAGUNA
Mailing Address - State:NM
Mailing Address - Zip Code:87026
Mailing Address - Country:US
Mailing Address - Phone:505-552-1013
Mailing Address - Fax:505-552-9569
Practice Address - Street 1:I40 W 114 BLDG 1125
Practice Address - Street 2:
Practice Address - City:LAGUNA
Practice Address - State:NM
Practice Address - Zip Code:87026
Practice Address - Country:US
Practice Address - Phone:505-552-1013
Practice Address - Fax:505-552-9569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000E7009Medicaid