=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184992612
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAOS PUEBLO CMS ADMINISTRATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2011
-----------------------------------------------------
Last Update Date | 12/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 230 ROTTEN TREE ROAD
-----------------------------------------------------
City | TAOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-758-7824
-----------------------------------------------------
Fax | 575-758-3346
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1846
-----------------------------------------------------
City | TAOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87571-1846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-758-7824
-----------------------------------------------------
Fax | 575-758-3346
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIVISION DIRECTOR
-----------------------------------------------------
Name | MRS. MAXINE NAKAI
-----------------------------------------------------
Credential | MSW, MPH
-----------------------------------------------------
Telephone | 575-758-7824
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 298
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------