=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578075016
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STATE OF NEW MEXICO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2017
-----------------------------------------------------
Last Update Date | 10/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 72 GAIL HARRIS ST
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88203-8116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-347-3400
-----------------------------------------------------
Fax | 575-347-5177
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 72 GAIL HARRIS ST
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88203-8116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-347-3400
-----------------------------------------------------
Fax | 575-347-5177
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JOSE LUIS GURROLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 575-347-3410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 284300000X
-----------------------------------------------------
Taxonomy Name | Special Hospital
-----------------------------------------------------
License Number | 6026
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------