Healthcare Provider Details

I. General information

NPI: 1942365176
Provider Name (Legal Business Name): INTERFAITH-LEAP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 04/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JOHN HYSON DR.
CHIMAYO NM
87522
US

IV. Provider business mailing address

PO BOX 3220
FAIRVIEW NM
87533-3220
US

V. Phone/Fax

Practice location:
  • Phone: 505-351-2163
  • Fax: 505-351-2446
Mailing address:
  • Phone: 505-351-2163
  • Fax: 505-351-2446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberNM600922
License Number StateNM

VIII. Authorized Official

Name: MR. RAYMOND M CHAVEZ
Title or Position: EXCUTIVE DIRECTOR
Credential: ETC
Phone: 505-351-2163