Healthcare Provider Details

I. General information

NPI: 1437363678
Provider Name (Legal Business Name): STATE OF NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 06/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3695 HOT SPRINGS BLVD
LAS VEGAS NM
87701-9549
US

IV. Provider business mailing address

3695 HOT SPRINGS BLVD.
LAS VEGAS NM
87701-9549
US

V. Phone/Fax

Practice location:
  • Phone: 505-454-2254
  • Fax:
Mailing address:
  • Phone: 505-454-2100
  • Fax: 505-454-2130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES R. JARAMILLO
Title or Position: FINANCE DIRECTOR
Credential:
Phone: 505-454-2306