Healthcare Provider Details

I. General information

NPI: 1720367105
Provider Name (Legal Business Name): SOUTHWEST CARES CA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 08/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

552 AGUA FRIA ST
SANTA FE NM
87501-2508
US

IV. Provider business mailing address

PO BOX 32390
SANTA FE NM
87594-2390
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-3113
  • Fax: 505-982-2462
Mailing address:
  • Phone: 505-982-3113
  • Fax: 505-982-2462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: CARMINE MAROTTA
Title or Position: DIRECTOR
Credential:
Phone: 505-982-3113