Healthcare Provider Details

I. General information

NPI: 1669340816
Provider Name (Legal Business Name): VILLAGE RESTORATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2025
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 MOUNTAIN ROAD PL NE
ALBUQUERQUE NM
87110-7845
US

IV. Provider business mailing address

1209 MOUNTAIN ROAD PL NE
ALBUQUERQUE NM
87110-7845
US

V. Phone/Fax

Practice location:
  • Phone: 480-788-8509
  • Fax:
Mailing address:
  • Phone: 480-788-8509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSANA TORRES CISNEROS
Title or Position: ADMINISTRATOR
Credential:
Phone: 480-788-8509