Healthcare Provider Details

I. General information

NPI: 1942287370
Provider Name (Legal Business Name): STATE OF NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
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: 575-894-4200
  • Fax: 575-894-4291
Mailing address:
  • Phone: 575-894-4200
  • Fax: 575-894-4291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5363
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number5087
License Number StateNM

VIII. Authorized Official

Name: KENNETH SHULL
Title or Position: HOSPITAL ADMINISTRATOR
Credential:
Phone: 575-894-4216