Healthcare Provider Details

I. General information

NPI: 1861626145
Provider Name (Legal Business Name): THOREAU NAVAJO OUTREACH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 FIRST STREET
THOREAU NM
87323-0547
US

IV. Provider business mailing address

PO BOX 547
THOREAU NM
87323-0547
US

V. Phone/Fax

Practice location:
  • Phone: 505-862-7415
  • Fax: 505-862-7635
Mailing address:
  • Phone: 505-862-7415
  • Fax: 505-862-7635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number684
License Number StateNM

VIII. Authorized Official

Name: MS. CLARA TOLEDO
Title or Position: DIRECTOR
Credential:
Phone: 505-862-7415