Healthcare Provider Details

I. General information

NPI: 1902022130
Provider Name (Legal Business Name): LITTLE SISTERS OF THE POOR OF NEW MEXICO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 MARK AVE
GALLUP NM
87301-4822
US

IV. Provider business mailing address

1900 MARK AVE
GALLUP NM
87301-4822
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-6894
  • Fax: 505-722-4121
Mailing address:
  • Phone: 505-863-6894
  • Fax: 505-722-4121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number5119
License Number StateNM

VIII. Authorized Official

Name: MARY THOMAS D'MELLO
Title or Position: DIRECTOR
Credential:
Phone: 505-863-6894