Basic Information
| Provider Information | |||||||||
| NPI: | 1548323926 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIO ARRIBA HEALTH AND HUMAN SERVICES | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RACMOS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 94508 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871995408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053847352 | ||||||||
| FaxNumber: | 5052747338 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 N PASEO DE ONATE | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875323454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057533143 | ||||||||
| FaxNumber: | 5057531769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 10/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | REICHELT | ||||||||
| AuthorizedOfficialFirstName: | LAUREN | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR-HEALTH & HUMAN SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 5057533143 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RIO ARRIBA COUNTY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | M04710 | NM | N | Agencies | Case Management | 251E00000X | N | Agencies | Home Health | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 41055853 | 05 | NM | MEDICAID | NM600621 | 01 | NM | PROVIDER ID | OTHER |