Provider Demographics
NPI:1386933620
Name:A CENTER FOR FUNCTION AND CREATIVITY
Entity type:Organization
Organization Name:A CENTER FOR FUNCTION AND CREATIVITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HOBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-890-0868
Mailing Address - Street 1:10701 CORRALES BLVD NW
Mailing Address - Street 2:SUITE 17
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-1087
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10701 CORRALES BLVD NW
Practice Address - Street 2:SUITE 17
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-1087
Practice Address - Country:US
Practice Address - Phone:505-890-0868
Practice Address - Fax:505-898-0169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM75988721251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM75988721Medicaid