Healthcare Provider Details

I. General information

NPI: 1578730230
Provider Name (Legal Business Name): STATE OF NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 08/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

992 S BROADWAY
TRUTH OR CONSEQUENCES NM
87901-3198
US

IV. Provider business mailing address

992 S BROADWAY
TRUTH OR CONSEQUENCES NM
87901-3198
US

V. Phone/Fax

Practice location:
  • Phone: 575-894-4254
  • Fax: 575-894-4294
Mailing address:
  • Phone: 575-894-4254
  • Fax: 575-894-4291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5087
License Number StateNM

VIII. Authorized Official

Name: MRS. MARIE R RICHTER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 575-894-4216