Healthcare Provider Details

I. General information

NPI: 1861695769
Provider Name (Legal Business Name): SANTA FE MOUNTAIN CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 BISHOPS LODGE ROAD
TESUQUE NM
87574-0449
US

IV. Provider business mailing address

PO BOX 449
TESUQUE NM
87574-0449
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-6158
  • Fax: 505-983-0460
Mailing address:
  • Phone: 505-983-6158
  • Fax: 505-983-0460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JUAN DIXON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 505-490-3549