Healthcare Provider Details

I. General information

NPI: 1184208225
Provider Name (Legal Business Name): PUEBLO DE SAN ILDEFONSO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 03/20/2022
Certification Date: 03/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 TUNYO PO
SANTA FE NM
87506-7258
US

IV. Provider business mailing address

2 TUNYO PO
SANTA FE NM
87506-7258
US

V. Phone/Fax

Practice location:
  • Phone: 505-455-2395
  • Fax:
Mailing address:
  • Phone: 505-455-2395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: TROY CAMPBELL
Title or Position: DIRECTOR HEALTH AND HUMAN SERVICES
Credential: LCSW
Phone: 505-692-5943