Healthcare Provider Details

I. General information

NPI: 1003292228
Provider Name (Legal Business Name): SACRED SPIRITS HOME HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 08/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 OLD LOOP
CONTINENTAL DIVIDE NM
87312-0145
US

IV. Provider business mailing address

PO BOX 145
CONTINENTAL DIVIDE NM
87312-0145
US

V. Phone/Fax

Practice location:
  • Phone: 505-240-3711
  • Fax:
Mailing address:
  • Phone: 505-240-3711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberR46467
License Number StateNM

VIII. Authorized Official

Name: MRS. TRACY JARAMILLO
Title or Position: HEALTH SERVICES ADMIN
Credential: RN
Phone: 505-240-3711