=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063008761
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUR CORNERS BEHAVIORAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2020
-----------------------------------------------------
Last Update Date | 12/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 S SECOND ST STE A
-----------------------------------------------------
City | GALLUP
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87301-5898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-722-2923
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3300 BOX CANYON AVE
-----------------------------------------------------
City | GALLUP
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87301-6940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-722-2923
-----------------------------------------------------
Fax | 505-722-2961
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHAITRY
-----------------------------------------------------
Name | MR. RICHARD K LAUGHTER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 505-879-6575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------