Basic Information
| Provider Information | |||||||||
| NPI: | 1992867998 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STATE OF NEW MEXICO | ||||||||
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| OtherOrganizationName: | NM BEHAVIORAL HEALTH INSTITUTE AT 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: | 3695 HOT SPRINGS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 877019549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054542100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 02/11/2015 | ||||||||
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| AuthorizedOfficialLastName: | JARAMILLO | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5054542306 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STATE OF NEW MEXICO | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 3035 | NM | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 283Q00000X | 6011 | NM | N | Hospitals | Psychiatric Hospital | 322D00000X | 7257 | NM | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 313M00000X | 5067 | NM | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | NM600303 | 05 | NM | MEDICAID | I0126 | 05 | NM | MEDICAID | 96296 | 05 | NM | MEDICAID | 50724 | 05 | NM | MEDICAID | M1545 | 05 | NM | MEDICAID |