Basic Information
| Provider Information | |||||||||
| NPI: | 1912995242 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-COUNTY COMMUNITY SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94508 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053847352 | ||||||||
| FaxNumber: | 5052747338 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 PASEO DEL CANON WEST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TAOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757585857 | ||||||||
| FaxNumber: | 5757585860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | GROSS | ||||||||
| AuthorizedOfficialFirstName: | RODNEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5757585857 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 3039B1 | NM | N | Agencies | Case Management | 261QM0801X | NM | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QR0800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Recovery Care |
ID Information
| ID | Type | State | Issuer | Description | 51409 | 05 | NM | MEDICAID |