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General NPI Number Information
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NPI Number | 1275842478
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Entity Type | Organization
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Legal Business Name | CANYON LIGHT INC.
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Dates
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Enumeration Date | 10/05/2010
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Last Update Date | 10/05/2010
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Provider Practice Location Address
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Address Line | 1301 CUBA AVE
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City | ALAMOGORDO
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State | NM
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Zip | 88310-5727
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Country | US
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Telephone | 575-437-2453
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Fax | 575-443-1504
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Provider Business Mailing Address
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Address Line | PO BOX 114
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City | ALAMOGORDO
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State | NM
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Zip | 88311-0114
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Country | US
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Telephone | 575-437-2453
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Fax | 575-443-1504
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | MR. JOHN P BALDONADO
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Credential | L.A.D.A.C.
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Telephone | 575-430-6913
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | NM
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