MEDICARE: AMIKIDS SANDOVAL, INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251S00000X	Community/Behavioral Health Agency
2	251B00000X	Case Management Agency
3	320800000X	Mental Illness Community Based Residential Treatment Facility
4	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407376585
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMIKIDS SANDOVAL, INC.

Provider Business Mailing Address
First Line	:	851 ANDREA DR BLDG E
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87401-6726
Country	:	US
Telephone Number	:	505-346-0075
Fax Number	:

Provider Business Practice Location Address
First Line	:	851 ANDREA DR STE 4
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87401-6726
Country	:	US
Telephone Number	:	505-220-1258
Fax Number	:	505-592-1141

Authorized Official
Title or Position	:	VICE PRESIDENT, SUPPORT SERVICES
Name	:	ROSEMARY BRACKMAN
Credential	:
Telephone Number	:	813-887-3300

Provider Enumeration Date	:	06/21/2017
Last Update Date	:	03/23/2026

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Directions to “AMIKIDS SANDOVAL, INC. ” Practice Location

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