Basic Information
Provider Information | |||||||||
NPI: | 1700945367 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DESERT VIEW, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6100 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | NM | ||||||||
PostalCode: | 874023034 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5053267878 | ||||||||
FaxNumber: | 5053267879 | ||||||||
Practice Location | |||||||||
Address1: | 6100 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | NM | ||||||||
PostalCode: | 874023034 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5053267878 | ||||||||
FaxNumber: | 5053267879 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/08/2006 | ||||||||
LastUpdateDate: | 07/23/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | QUEVEDO | ||||||||
AuthorizedOfficialFirstName: | RICK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5053267878 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 251S00000X | 122 | NM | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 0078336 | 05 | NM |   | MEDICAID |