Healthcare Provider Details

I. General information

NPI: 1265024103
Provider Name (Legal Business Name): AVALON RANCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 N MESQUITE ST
CARLSBAD NM
88220-4960
US

IV. Provider business mailing address

106 N MESQUITE ST
CARLSBAD NM
88220-4960
US

V. Phone/Fax

Practice location:
  • Phone: 575-302-8304
  • Fax:
Mailing address:
  • Phone: 575-302-8304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY SUSAN ROGGE-ROGERS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 575-302-8304