Healthcare Provider Details

I. General information

NPI: 1023934379
Provider Name (Legal Business Name): TRISTON SHANE ERIACHO LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BIA RT. 125 BEHAVIORAL HEALTH ROAD
PINE HILL NM
87357
US

IV. Provider business mailing address

PO BOX 490
PINEHILL NM
87357-0490
US

V. Phone/Fax

Practice location:
  • Phone: 505-775-3353
  • Fax: 505-775-3630
Mailing address:
  • Phone: 505-775-3353
  • Fax: 505-775-3630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2023-0738
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: