Healthcare Provider Details

I. General information

NPI: 1619150463
Provider Name (Legal Business Name): SANTA MARIA EL MIRADOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 12/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 S PACHECO ST SUITE 100
SANTA FE NM
87505-5473
US

IV. Provider business mailing address

2041 S PACHECO ST SUITE 100
SANTA FE NM
87505-5473
US

V. Phone/Fax

Practice location:
  • Phone: 505-424-7700
  • Fax: 505-424-7707
Mailing address:
  • Phone: 505-424-7700
  • Fax: 505-424-7707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number02347611007
License Number StateNM

VIII. Authorized Official

Name: MR. ELOY F DURAN
Title or Position: DEPUTY DIRECTOR OF FINANCE
Credential:
Phone: 505-428-2004