Healthcare Provider Details

I. General information

NPI: 1093689713
Provider Name (Legal Business Name): RANCHO RIOS DOMINGUEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2025
Last Update Date: 10/04/2025
Certification Date: 10/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 EL PESCADO RD
CHAMBERINO NM
88027-9005
US

IV. Provider business mailing address

PO BOX 163
CHAMBERINO NM
88027-0163
US

V. Phone/Fax

Practice location:
  • Phone: 575-621-5913
  • Fax:
Mailing address:
  • Phone: 575-621-5913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. JESSIE JOANNE RIOS
Title or Position: INSTRUCTOR COACH
Credential: CBEIP
Phone: 575-621-5913