Basic Information
| Provider Information | |||||||||
| NPI: | 1437363678 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STATE OF NEW MEXICO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3695 HOT SPRINGS BLVD. | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 877019549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054542100 | ||||||||
| FaxNumber: | 5054542130 | ||||||||
| Practice Location | |||||||||
| Address1: | 3695 HOT SPRINGS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 877019549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054542254 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 06/02/2009 | ||||||||
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| AuthorizedOfficialLastName: | JARAMILLO | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5054542306 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 104100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | D0769 | 05 | NM | MEDICAID |