Healthcare Provider Details

I. General information

NPI: 1376964841
Provider Name (Legal Business Name): MANDALA GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2013
Last Update Date: 12/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19478 HIGHWAY 314
BELEN NM
87002-8223
US

IV. Provider business mailing address

PO BOX 323
JARALES NM
87023-0323
US

V. Phone/Fax

Practice location:
  • Phone: 505-859-0814
  • Fax:
Mailing address:
  • Phone: 505-859-0814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2010081
License Number StateNM

VIII. Authorized Official

Name: BARBARA J SMITH
Title or Position: OWNER
Credential: LSW
Phone: 505-859-0814