Healthcare Provider Details

I. General information

NPI: 1912720335
Provider Name (Legal Business Name): FULLCIRCLE COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 02/26/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6136 4TH ST NW STE C
LOS RANCHOS NM
87107-5367
US

IV. Provider business mailing address

6136 4TH ST NW STE C
LOS RANCHOS NM
87107-5367
US

V. Phone/Fax

Practice location:
  • Phone: 505-414-1162
  • Fax:
Mailing address:
  • Phone: 505-414-1162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW MOLINA
Title or Position: PRESIDENT & CEO
Credential:
Phone: 505-414-1162