Healthcare Provider Details

I. General information

NPI: 1548452949
Provider Name (Legal Business Name): TRUST IN GOD REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 BLUEBERRY HILL ROAD
EL PRADO NM
87529
US

IV. Provider business mailing address

P.O. BOX 6499
TAOS NM
87511
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-3879
  • Fax:
Mailing address:
  • Phone: 575-758-3879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM06217
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberCU00010276
License Number StateNM

VIII. Authorized Official

Name: MR. FRED GONZALES
Title or Position: BOARD PRESIDENT
Credential:
Phone: 575-758-3879