1639382542 NPI number — NMDOH FAMILY INFANT TODDLER PROGRAM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639382542 NPI number — NMDOH FAMILY INFANT TODDLER PROGRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NMDOH FAMILY INFANT TODDLER PROGRAM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639382542
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1190 SAINT FRANCIS DRIVE
Provider Second Line Business Mailing Address:
PO BOX 26110
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87502-6110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-827-1711
Provider Business Mailing Address Fax Number:
505-827-2455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1190 SAINT FRANCIS DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87502-6110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-827-1711
Provider Business Practice Location Address Fax Number:
505-827-2455
Provider Enumeration Date:
05/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOMM
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
Authorized Official Title or Position:
EARLY CHILDHOOD COORDINATOR
Authorized Official Telephone Number:
505-827-2578

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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