MEDICARE: INNER PEACE OUTREACH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1023647096
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNER PEACE OUTREACH

Provider Business Mailing Address
First Line	:	211 CLAREMONT AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-1513
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3107 SAN MATEO BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-1921
Country	:	US
Telephone Number	:	505-712-6447
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	COURTNEY HARRING
Credential	:
Telephone Number	:	678-761-5956

Provider Enumeration Date	:	04/02/2020
Last Update Date	:	01/13/2021

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Directions to “INNER PEACE OUTREACH ” Practice Location

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