Healthcare Provider Details

I. General information

NPI: 1184992612
Provider Name (Legal Business Name): TAOS PUEBLO CMS ADMINISTRATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 ROTTEN TREE ROAD
TAOS NM
87571
US

IV. Provider business mailing address

PO BOX 1846
TAOS NM
87571-1846
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-7824
  • Fax: 575-758-3346
Mailing address:
  • Phone: 575-758-7824
  • Fax: 575-758-3346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number298
License Number StateNM

VIII. Authorized Official

Name: MRS. MAXINE NAKAI
Title or Position: DIVISION DIRECTOR
Credential: MSW, MPH
Phone: 575-758-7824