Healthcare Provider Details

I. General information

NPI: 1639382542
Provider Name (Legal Business Name): NMDOH FAMILY INFANT TODDLER PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 SAINT FRANCIS DRIVE
SANTA FE NM
87502-6110
US

IV. Provider business mailing address

1190 SAINT FRANCIS DRIVE PO BOX 26110
SANTA FE NM
87502-6110
US

V. Phone/Fax

Practice location:
  • Phone: 505-827-1711
  • Fax: 505-827-2455
Mailing address:
  • Phone: 505-827-1711
  • Fax: 505-827-2455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ANDREW GOMM
Title or Position: EARLY CHILDHOOD COORDINATOR
Credential:
Phone: 505-827-2578