Healthcare Provider Details

I. General information

NPI: 1245804301
Provider Name (Legal Business Name): MESCALERO APACHE TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 05/13/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 SUNSET LOOP
MESCALERO NM
88340-8834
US

IV. Provider business mailing address

PO BOX 228
MESCALERO NM
88340-0228
US

V. Phone/Fax

Practice location:
  • Phone: 575-464-4432
  • Fax: 575-464-4331
Mailing address:
  • Phone: 575-464-4432
  • Fax: 575-464-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: VERALYN MENDEZ
Title or Position: DIRECTOR
Credential: MSW
Phone: 575-464-4432