Healthcare Provider Details

I. General information

NPI: 1912667700
Provider Name (Legal Business Name): NOVA III BEHAVIORAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2418 E HIGHWAY 66
GALLUP NM
87301-4767
US

IV. Provider business mailing address

2418 E HIGHWAY 66
GALLUP NM
87301-4767
US

V. Phone/Fax

Practice location:
  • Phone: 505-297-3967
  • Fax:
Mailing address:
  • Phone: 505-297-3967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID CONEJO
Title or Position: CEO
Credential:
Phone: 903-820-1142