=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083986871
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANETTE VICE TOLEDO VICE LSAA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2012
-----------------------------------------------------
Last Update Date | 02/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | HC 79 BOX 1510
-----------------------------------------------------
City | OJO ENCINO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87013-9612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-731-1500
-----------------------------------------------------
Fax | 505-731-1502
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | HC 79 BOX 1508
-----------------------------------------------------
City | OJO ENCINO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87013-9612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-731-1505
-----------------------------------------------------
Fax | 505-731-1502
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 070481
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------