Healthcare Provider Details

I. General information

NPI: 1861174856
Provider Name (Legal Business Name): CAIN MORA CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1273 S 2ND ST
RATON NM
87740-2234
US

IV. Provider business mailing address

400 GOLD AVE SW # 1300E
ALBUQUERQUE NM
87102-3283
US

V. Phone/Fax

Practice location:
  • Phone: 575-733-0003
  • Fax:
Mailing address:
  • Phone: 505-715-4610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: