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General NPI Number Information
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NPI Number | 1528458114
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Entity Type | Organization
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Legal Business Name | CASA MILAGRO
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Dates
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Enumeration Date | 02/03/2015
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Last Update Date | 06/29/2021
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Provider Practice Location Address
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Address Line | 49 CAMINO BAJO
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City | SANTA FE
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State | NM
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Zip | 87508-8614
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Country | US
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Telephone | 505-474-7684
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Fax | 505-438-4877
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Provider Business Mailing Address
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Address Line | 49 CAMINO BAJO
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City | SANTA FE
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State | NM
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Zip | 87508-8614
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Country | US
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Telephone | 505-474-7684
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Fax | 505-438-4877
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DESIREE BERNARD
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Credential |
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Telephone | 505-474-7684
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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 |
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Taxonomy #2
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number | 5817
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 5817
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License Number State | NM
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