Healthcare Provider Details

I. General information

NPI: 1649328147
Provider Name (Legal Business Name): TOBOSA DEVELOPMENTAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E SUMMIT ST
ROSWELL NM
88203-5619
US

IV. Provider business mailing address

110 E SUMMIT ST
ROSWELL NM
88203-5619
US

V. Phone/Fax

Practice location:
  • Phone: 505-624-1025
  • Fax: 505-623-6444
Mailing address:
  • Phone: 505-624-1025
  • Fax: 505-623-6444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNM

VIII. Authorized Official

Name: MR. JOE MADRID
Title or Position: EXECUTIVE DIRECTOR
Credential: MASTERS
Phone: 505-624-1025