Healthcare Provider Details

I. General information

NPI: 1407376585
Provider Name (Legal Business Name): AMIKIDS SANDOVAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 ANDREA DR STE 4
FARMINGTON NM
87401-6726
US

IV. Provider business mailing address

851 ANDREA DR BLDG E
FARMINGTON NM
87401-6726
US

V. Phone/Fax

Practice location:
  • Phone: 505-220-1258
  • Fax: 505-592-1141
Mailing address:
  • Phone: 505-346-0075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ROSEMARY BRACKMAN
Title or Position: VICE PRESIDENT, SUPPORT SERVICES
Credential:
Phone: 813-887-3300