Basic Information
| Provider Information | |||||||||
| NPI: | 1407057607 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATE OF NEW MEXICO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | NEW MEXICO BEHAVIORAL HEALTH INSTITUE AT LAS VEGAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3695 HOT SPRINGS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 877019549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054542100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3695 HOT SPRINGS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 877019549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054542100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 04/30/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JARAMILLO | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5054542306 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 32D0653275 | NM | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 52431 | 05 | NM | MEDICAID |