Healthcare Provider Details

I. General information

NPI: 1922094770
Provider Name (Legal Business Name): STATE OF NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 GAIL HARRIS AVE
ROSWELL NM
88203-8116
US

IV. Provider business mailing address

72 GAIL HARRIS AVE
ROSWELL NM
88203-8116
US

V. Phone/Fax

Practice location:
  • Phone: 575-347-3400
  • Fax: 575-347-5177
Mailing address:
  • Phone: 575-347-3400
  • Fax: 575-347-5177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number6026
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number6026
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code284300000X
TaxonomySpecial Hospital
License Number6026
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6026
License Number StateNM

VIII. Authorized Official

Name: MS. JANIE DAVIES
Title or Position: HOSPITAL ADMINISTRATOR
Credential:
Phone: 575-347-3400