Provider Demographics
NPI:1356408256
Name:GOLDEN SPREAD RURAL FRONTIER
Entity type:Organization
Organization Name:GOLDEN SPREAD RURAL FRONTIER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-374-6207
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NM
Mailing Address - Zip Code:88415-0096
Mailing Address - Country:US
Mailing Address - Phone:505-374-6207
Mailing Address - Fax:505-374-0566
Practice Address - Street 1:113 WALNUT ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NM
Practice Address - Zip Code:88415-3049
Practice Address - Country:US
Practice Address - Phone:505-374-6207
Practice Address - Fax:505-374-0566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM02-381344-00-0101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty