Healthcare Provider Details

I. General information

NPI: 1629524434
Provider Name (Legal Business Name): ALTA MIRA SPECIALIZED FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 CARLISLE BLVD NE
ALBUQUERQUE NM
87110-5619
US

IV. Provider business mailing address

1605 CARLISLE BLVD NE
ALBUQUERQUE NM
87110-5619
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-0801
  • Fax: 505-262-0845
Mailing address:
  • Phone: 505-262-0801
  • Fax: 505-262-0845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JIM COPELAND
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 505-366-2117