Healthcare Provider Details

I. General information

NPI: 1528458114
Provider Name (Legal Business Name): CASA MILAGRO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2015
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 CAMINO BAJO
SANTA FE NM
87508-8614
US

IV. Provider business mailing address

49 CAMINO BAJO
SANTA FE NM
87508-8614
US

V. Phone/Fax

Practice location:
  • Phone: 505-474-7684
  • Fax: 505-438-4877
Mailing address:
  • Phone: 505-474-7684
  • Fax: 505-438-4877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number5817
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number5817
License Number StateNM

VIII. Authorized Official

Name: DESIREE BERNARD
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 505-474-7684