Healthcare Provider Details

I. General information

NPI: 1750418281
Provider Name (Legal Business Name): REGION IX DEVELOPMENTAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 SUDDERTH DR
RUIDOSO NM
88345-6103
US

IV. Provider business mailing address

1400 SUDDERTH DR
RUIDOSO NM
88345-6103
US

V. Phone/Fax

Practice location:
  • Phone: 505-257-3105
  • Fax: 505-257-1033
Mailing address:
  • Phone: 505-257-2368
  • Fax: 505-257-1033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number07665.0070405
License Number StateNM

VIII. Authorized Official

Name: MRS. SANDY GLADDEN
Title or Position: DIRECTOR
Credential:
Phone: 505-257-3105