Provider Demographics
NPI:1033716972
Name:SANTA FE RECOVERY CENTER
Entity Type:Organization
Organization Name:SANTA FE RECOVERY CENTER
Other - Org Name:FOUR CORNERS DETOX RECOVERY
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING AND BILLING
Authorized Official - Prefix:
Authorized Official - First Name:LOU
Authorized Official - Middle Name:
Authorized Official - Last Name:DURAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-270-3966
Mailing Address - Street 1:2504 CAMINO ENTRADA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-4851
Mailing Address - Country:US
Mailing Address - Phone:505-471-4985
Mailing Address - Fax:
Practice Address - Street 1:2105 HASLER VALLEY RD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87305
Practice Address - Country:US
Practice Address - Phone:505-471-9856
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SANTA FE RECOVERY CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-05
Last Update Date:2023-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM82536716Medicaid