MEDICARE: NMDOH FAMILY INFANT TODDLER PROGRAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1639382542
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NMDOH FAMILY INFANT TODDLER PROGRAM

Provider Business Mailing Address
First Line	:	1190 SAINT FRANCIS DRIVE
Second Line	:	PO BOX 26110
City	:	SANTA FE
State	:	NM
Zip	:	87502-6110
Country	:	US
Telephone Number	:	505-827-1711
Fax Number	:	505-827-2455

Provider Business Practice Location Address
First Line	:	1190 SAINT FRANCIS DRIVE
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87502-6110
Country	:	US
Telephone Number	:	505-827-1711
Fax Number	:	505-827-2455

Authorized Official
Title or Position	:	EARLY CHILDHOOD COORDINATOR
Name	:	ANDREW GOMM
Credential	:
Telephone Number	:	505-827-2578

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	08/22/2020

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