Healthcare Provider Details

I. General information

NPI: 1003284654
Provider Name (Legal Business Name): COMPOSTELA COMMUNITY AND FAMILY CULTURAL INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2015
Last Update Date: 09/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 SALAZAR RD
TAOS NM
87571-8233
US

IV. Provider business mailing address

PO BOX 2173
EL PRADO NM
87529-2173
US

V. Phone/Fax

Practice location:
  • Phone: 575-613-2008
  • Fax:
Mailing address:
  • Phone: 575-776-2752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberR12314
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License NumberR12314
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number12732
License Number StateNM

VIII. Authorized Official

Name: DR. TRINIDAD DE JESUS ARGUELLO
Title or Position: CEO
Credential: PH.D.,LISW, PMHBC-RN
Phone: 575-776-2752