Healthcare Provider Details

I. General information

NPI: 1073181061
Provider Name (Legal Business Name): PICURIS PUEBLO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 A PUEBLO VIEW ROAD
PENASCO NM
87553
US

IV. Provider business mailing address

PO BOX 127
PENASCO NM
87553
US

V. Phone/Fax

Practice location:
  • Phone: 575-587-2519
  • Fax: 505-579-2660
Mailing address:
  • Phone: 575-587-2519
  • Fax: 505-579-9129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: CRAIG QUANCHELLO
Title or Position: GOVERNOR, PICURIS PUEBLO
Credential: LMSW,LADAC,CADC,CS
Phone: 575-587-2519