Basic Information
| Provider Information | |||||||||
| NPI: | 1912918103 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STATE OF NEW MEXICO | ||||||||
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| OtherOrganizationName: | NM BEHAVIORAL HEALTH INSTITUTE @ 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: | 5054542130 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 FRIEDMAN AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 877014231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054545100 | ||||||||
| FaxNumber: | 5054540397 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MARTINEZ | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERIM HOSPITAL ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5054542100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 76-135 | NM | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 03038 | 05 | NM | MEDICAID |