Provider Demographics
NPI:1992983316
Name:CIVIGENICS
Entity type:Organization
Organization Name:CIVIGENICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLANCY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-226-2900
Mailing Address - Street 1:P.O. BOX 98
Mailing Address - Street 2:NEW MEXICO HIGHTWAY 220
Mailing Address - City:FORT STANTON
Mailing Address - State:NM
Mailing Address - Zip Code:88323
Mailing Address - Country:US
Mailing Address - Phone:505-354-8305
Mailing Address - Fax:
Practice Address - Street 1:106 KIT CARSON ROAD
Practice Address - Street 2:
Practice Address - City:FORT STANTON
Practice Address - State:NM
Practice Address - Zip Code:88323
Practice Address - Country:US
Practice Address - Phone:505-354-8305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY EDUCATION CENTERS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility