Healthcare Provider Details

I. General information

NPI: 1699091389
Provider Name (Legal Business Name): GUADALUPE PSYCHIATRIC AND MENTAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 07/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 21ST ST SE STE 7
RIO RANCHO NM
87124-4030
US

IV. Provider business mailing address

2003 SOUTHERN BLVD SE STE 102-214
RIO RANCHO NM
87124-3751
US

V. Phone/Fax

Practice location:
  • Phone: 505-459-6101
  • Fax:
Mailing address:
  • Phone: 505-459-6101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20030591
License Number StateNM

VIII. Authorized Official

Name: YVONNE D HALL
Title or Position: SOLE OWNER
Credential: MD
Phone: 505-459-6101