Provider Demographics
NPI:1003917261
Name:PMS WESTERN NM BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:PMS WESTERN NM BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSR AIDE
Authorized Official - Prefix:
Authorized Official - First Name:DORRIE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:LAYCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-863-3828
Mailing Address - Street 1:2025 E AZTEC AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 IDAHO CIR
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5443
Practice Address - Country:US
Practice Address - Phone:505-863-3828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services