Healthcare Provider Details

I. General information

NPI: 1154350205
Provider Name (Legal Business Name): TAOS CLINIC FOR CHILDREN AND YOUTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 05/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1393 WEIMER RD
TAOS NM
87571-6253
US

IV. Provider business mailing address

1393 WEIMER ROAD
TAOS NM
87571-6253
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-8651
  • Fax: 575-758-7811
Mailing address:
  • Phone: 575-758-8651
  • Fax: 575-758-7811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DICK SCHLARBAUM
Title or Position: OFFICE MANAGER
Credential:
Phone: 575-758-8651