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General NPI Number Information
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NPI Number | 1639382542
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Entity Type | Organization
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Legal Business Name | NMDOH FAMILY INFANT TODDLER PROGRAM
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Dates
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Enumeration Date | 05/07/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1190 SAINT FRANCIS DRIVE
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City | SANTA FE
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State | NM
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Zip | 87502-6110
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Country | US
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Telephone | 505-827-1711
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Fax | 505-827-2455
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Provider Business Mailing Address
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Address Line | 1190 SAINT FRANCIS DRIVE PO BOX 26110
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City | SANTA FE
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State | NM
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Zip | 87502-6110
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Country | US
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Telephone | 505-827-1711
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Fax | 505-827-2455
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Authorized Official
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Title or Position | EARLY CHILDHOOD COORDINATOR
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Name | ANDREW GOMM
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Credential |
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Telephone | 505-827-2578
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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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