Healthcare Provider Details

I. General information

NPI: 1174096945
Provider Name (Legal Business Name): ANTHONY CHARLES MASON COMMUNITY SUPPORT WO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 S SOLANO DR
LAS CRUCES NM
88001-3758
US

IV. Provider business mailing address

159 SHAWNEE
LAS CRUCES NM
88007-1144
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-4004
  • Fax: 575-522-9017
Mailing address:
  • Phone: 575-296-4990
  • Fax: 575-522-9017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: