Basic Information
| Provider Information | |||||||||
| NPI: | 1528614856 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEZ | ||||||||
| FirstName: | ROEMILLO | ||||||||
| MiddleName: | |||||||||
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| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2245 | ||||||||
| Address2: | |||||||||
| City: | KIRTLAND | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874172245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058605227 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2960 RODEO PARK DR W | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875056351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059869633 | ||||||||
| FaxNumber: | 5058201209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2019 | ||||||||
| LastUpdateDate: | 08/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1528614856 | 01 | NPI | OTHER |