Healthcare Provider Details

I. General information

NPI: 1295971505
Provider Name (Legal Business Name): TAOS PUEBLO DIVISION OF HEALTH AND COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 GOAT SPRINGS RD
TAOS NM
87571
US

IV. Provider business mailing address

PO BOX 1846
TAOS NM
87571
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 Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. SHAWN DURAN
Title or Position: TRIBAL PROGRAM ADMINISTRATOR
Credential:
Phone: 575-758-8626