Healthcare Provider Details

I. General information

NPI: 1578794871
Provider Name (Legal Business Name): NORTH CENTRAL COMMUNITY BASED SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16542 HWY 84
CHAMA NM
87520-0617
US

IV. Provider business mailing address

PO BOX 617 16542 HWY 84
CHAMA NM
87520-0617
US

V. Phone/Fax

Practice location:
  • Phone: 575-756-2327
  • Fax: 575-756-1897
Mailing address:
  • Phone: 575-756-2327
  • Fax: 575-756-1897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNM

VIII. Authorized Official

Name: MRS. PATRICIA SERNA
Title or Position: EXECUTIVE DIRECTOR
Credential: LISW
Phone: 575-756-2327