Healthcare Provider Details

I. General information

NPI: 1457539322
Provider Name (Legal Business Name): STATE OF NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 S PACHECO ST
SANTA FE NM
87505-3991
US

IV. Provider business mailing address

PO BOX 2348
SANTA FE NM
87504-2348
US

V. Phone/Fax

Practice location:
  • Phone: 505-827-3100
  • Fax:
Mailing address:
  • Phone: 505-827-3100
  • Fax:

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: ROBERT STEVENS
Title or Position: CHIEF
Credential: RPH
Phone: 505-827-6207