Healthcare Provider Details

I. General information

NPI: 1245554419
Provider Name (Legal Business Name): ALBUQUERQUE HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2010
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 MONTANO RD NW
ALBUQUERQUE NM
87107-5030
US

IV. Provider business mailing address

172 MONTANO RD. NW
ALBUQUERQUE NM
87107
US

V. Phone/Fax

Practice location:
  • Phone: 505-344-4427
  • Fax:
Mailing address:
  • Phone: 505-344-4427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State

VIII. Authorized Official

Name: DR. SIVAN WILSON
Title or Position: CEO
Credential: PSYD
Phone: 505-260-9917