Healthcare Provider Details

I. General information

NPI: 1215932587
Provider Name (Legal Business Name): MOUNTAIN HOME HEALTH CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 PASEO DEL PUEBLO SUR # 180
TAOS NM
87571-7023
US

IV. Provider business mailing address

PO BOX 2566
TAOS NM
87571-2566
US

V. Phone/Fax

Practice location:
  • Phone: 505-758-1024
  • Fax: 505-758-0560
Mailing address:
  • Phone: 575-758-4786
  • Fax: 575-758-0560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number6058A1
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number6479
License Number StateNM

VIII. Authorized Official

Name: BETTE MYERSON
Title or Position: FINANCE DIRECTOR
Credential:
Phone: 575-758-4786