Healthcare Provider Details

I. General information

NPI: 1376464594
Provider Name (Legal Business Name): NEW MEXICO WIC PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 S PACHECO ST
SANTA FE NM
87505-5472
US

IV. Provider business mailing address

2040 S PACHECO ST
SANTA FE NM
87505-5472
US

V. Phone/Fax

Practice location:
  • Phone: 505-476-8800
  • Fax: 505-476-8900
Mailing address:
  • Phone: 505-476-8800
  • Fax: 505-476-8900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE D CISNEROS
Title or Position: MEDICAID MANAGED CARE CONTRACTS
Credential:
Phone: 505-623-1256