MEDICARE: NATIONAL LATINO BEHAVIORAL HEALTH ASSOCIATION

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

General Provider Information

NPI Number	:	1659119402
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATIONAL LATINO BEHAVIORAL HEALTH ASSOCIATION

Provider Business Mailing Address
First Line	:	PO BOX 1360
Second Line	:
City	:	PENA BLANCA
State	:	NM
Zip	:	87041-1360
Country	:	US
Telephone Number	:	505-980-5156
Fax Number	:

Provider Business Practice Location Address
First Line	:	6555 ROBIN ST
Second Line	:
City	:	COCHITI LAKE
State	:	NM
Zip	:	87083-6025
Country	:	US
Telephone Number	:	505-980-5156
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. FRED R. SANDOVAL
Credential	:	MPA
Telephone Number	:	505-980-5156

Provider Enumeration Date	:	07/16/2024
Last Update Date	:	07/16/2024

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