Healthcare Provider Details

I. General information

NPI: 1255622965
Provider Name (Legal Business Name): COYOTE CANYON REHABILITATION CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 04/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MILES EAST NAVAJO ROUTE #9
BRIMHALL NM
87310
US

IV. Provider business mailing address

PO BOX 158
BRIMHALL NM
87310-0158
US

V. Phone/Fax

Practice location:
  • Phone: 505-735-2261
  • Fax: 505-735-2013
Mailing address:
  • Phone: 505-735-2261
  • Fax: 505-735-2013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateNM

VIII. Authorized Official

Name: MR. MACDONALD AVERY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 505-735-2002