Healthcare Provider Details

I. General information

NPI: 1205219771
Provider Name (Legal Business Name): DISMAS HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 07/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 CANDELARIA
ALBUQUERQUE NM
87108
US

IV. Provider business mailing address

PO BOX 6101
ALBUQUERQUE NM
87197-6101
US

V. Phone/Fax

Practice location:
  • Phone: 505-343-0746
  • Fax: 505-345-4513
Mailing address:
  • Phone: 505-343-0746
  • Fax: 505-345-4513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberNPI#1902918055
License Number StateNM

VIII. Authorized Official

Name: MR. JAMES GIVENS
Title or Position: COMMUNITY SERVICE WORKER
Credential:
Phone: 505-343-0746