Healthcare Provider Details

I. General information

NPI: 1386870137
Provider Name (Legal Business Name): DISMAS HOUSE NM INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2009
Last Update Date: 06/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 CANDELARIA RD NW
ALBUQUERQUE NM
87107-2407
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 Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNM

VIII. Authorized Official

Name: RUSTY SMITH
Title or Position: EXECUTIVE DIRECTOR
Credential: REVEREND
Phone: 505-343-0746