Healthcare Provider Details

I. General information

NPI: 1063008761
Provider Name (Legal Business Name): FOUR CORNERS BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S SECOND ST STE A
GALLUP NM
87301-5898
US

IV. Provider business mailing address

3300 BOX CANYON AVE
GALLUP NM
87301-6940
US

V. Phone/Fax

Practice location:
  • Phone: 507-722-2923
  • Fax:
Mailing address:
  • Phone: 505-722-2923
  • Fax: 505-722-2961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD K LAUGHTER
Title or Position: PSYCHAITRY
Credential: M.D.
Phone: 505-879-6575