Healthcare Provider Details

I. General information

NPI: 1982730669
Provider Name (Legal Business Name): STATE OF NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date: 02/13/2017
Reactivation Date: 02/22/2017

III. Provider practice location address

41 FORT BAYARD ROAD
SANTA CLARA NM
88026
US

IV. Provider business mailing address

PO BOX 293
SANTA CLARA NM
88026-0293
US

V. Phone/Fax

Practice location:
  • Phone: 575-537-8600
  • Fax: 575-537-8869
Mailing address:
  • Phone: 575-537-8600
  • Fax: 575-537-3753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5011
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number5011
License Number StateNM

VIII. Authorized Official

Name: SHERRI BAYS
Title or Position: CFO
Credential:
Phone: 575-537-8606