Healthcare Provider Details

I. General information

NPI: 1063304921
Provider Name (Legal Business Name): SOUTHERN NEW MEXICO DIABETES OUTREACH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2025
Last Update Date: 07/16/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 S MAIN ST STE 700
LAS CRUCES NM
88001-1237
US

IV. Provider business mailing address

506 S MAIN ST STE 700
LAS CRUCES NM
88001-1237
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-0289
  • Fax:
Mailing address:
  • Phone: 575-522-0289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: MS. SELENA GOMEZ
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 575-522-0289