Healthcare Provider Details

I. General information

NPI: 1699245050
Provider Name (Legal Business Name): CHARLIE MIKE BASE CAMP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2018
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E IDAHO AVE STE 27
LAS CRUCES NM
88005-3242
US

IV. Provider business mailing address

PO BOX 1676
FAIRACRES NM
88033-1676
US

V. Phone/Fax

Practice location:
  • Phone: 575-571-1016
  • Fax:
Mailing address:
  • Phone: 575-571-1016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: CHARLES GATES
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 575-571-1016