Healthcare Provider Details

I. General information

NPI: 1750146767
Provider Name (Legal Business Name): MADELEINE JEANNE TREVINO, ASSOCIATE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2024
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 S GARDEN AVE
ROSWELL NM
88203-6866
US

IV. Provider business mailing address

110 E MESCALERO RD
ROSWELL NM
88201-6542
US

V. Phone/Fax

Practice location:
  • Phone: 575-625-6210
  • Fax: 575-627-0405
Mailing address:
  • Phone: 575-625-6210
  • Fax: 575-622-3325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: