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General NPI Number Information
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NPI Number | 1376089672
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Entity Type | Organization
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Legal Business Name | STATE OF NEW MEXICO-ALTSD
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Dates
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Enumeration Date | 01/10/2017
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Last Update Date | 01/10/2017
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Provider Practice Location Address
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Address Line | 2550 CERRILLOS ROAD
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City | SANTA FE
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State | NM
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Zip | 87505
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Country | US
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Telephone | 505-476-4577
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Fax |
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Provider Business Mailing Address
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Address Line | 2550 CERRILLOS RD
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City | SANTA FE
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State | NM
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Zip | 87505-3260
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Country | US
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Telephone | 505-476-4577
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Fax |
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Authorized Official
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Title or Position | DIVISION DIRECTOR
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Name | CARLOS L MOYA
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Credential |
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Telephone | 505-476-4577
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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