Provider Demographics
NPI:1548315864
Name:ENMU-ROSWELL SCHOOL BASED HEALTH CENTER
Entity type:Organization
Organization Name:ENMU-ROSWELL SCHOOL BASED HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENEVA
Authorized Official - Middle Name:JEWEL
Authorized Official - Last Name:DEARING
Authorized Official - Suffix:
Authorized Official - Credentials:CMA
Authorized Official - Phone:505-627-2808
Mailing Address - Street 1:PO BOX 6000
Mailing Address - Street 2:ATTN JANE BATSON SBHC
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-6000
Mailing Address - Country:US
Mailing Address - Phone:505-627-2808
Mailing Address - Fax:505-624-2290
Practice Address - Street 1:1601 E BLAND ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-7900
Practice Address - Country:US
Practice Address - Phone:505-627-2808
Practice Address - Fax:505-624-2290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM9A01Medicaid