Healthcare Provider Details

I. General information

NPI: 1063462323
Provider Name (Legal Business Name): MARY MARGARET THOMAS CASE MANAGER
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 SIPAUP ROAD BOX 6952
TAOS NM
87571
US

IV. Provider business mailing address

6 ORTIZ ROAD
RANCHOS DE TAOS NM
87557
US

V. Phone/Fax

Practice location:
  • Phone: 505-758-5857
  • Fax: 505-758-2832
Mailing address:
  • Phone: 505-586-0066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: