Healthcare Provider Details

I. General information

NPI: 1417370131
Provider Name (Legal Business Name): GREATER SANTA ROSA COUNCIL ON ALCOHOLISM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1047 LAKE DR
SANTA ROSA NM
88435-2561
US

IV. Provider business mailing address

419 S 2ND ST
TUCUMCARI NM
88401-2859
US

V. Phone/Fax

Practice location:
  • Phone: 575-472-5383
  • Fax: 575-472-5384
Mailing address:
  • Phone: 575-472-5383
  • Fax: 575-472-5384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberI-04593
License Number StateNM

VIII. Authorized Official

Name: CAYETANA ZAMORA
Title or Position: EXECUTIVE DIRECTOR OF OPERATIONS
Credential:
Phone: 575-472-5383