Healthcare Provider Details

I. General information

NPI: 1124189048
Provider Name (Legal Business Name): NEW MEXICO DEPARTMENT OF HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 ESTANCIA ROAD
BELEN NM
87002
US

IV. Provider business mailing address

445 CAMINO DEL REY SW SUITE A
LOS LUNAS NM
87031
US

V. Phone/Fax

Practice location:
  • Phone: 505-864-4015
  • Fax: 505-841-5316
Mailing address:
  • Phone: 505-222-0900
  • Fax: 505-222-0933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number5240
License Number StateNM

VIII. Authorized Official

Name: CAITLYN BLAINE
Title or Position: FINANCE DIRECTOR
Credential:
Phone: 505-264-5456