Provider Demographics
NPI:1063641819
Name:NM DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:NM DEPARTMENT OF HEALTH
Other - Org Name:FT BAYARY MEDICAL CENTTER, YUCCA LODGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:CORONA
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LADAC, BS
Authorized Official - Phone:575-537-8831
Mailing Address - Street 1:PO BOX 36216
Mailing Address - Street 2:
Mailing Address - City:FORT BAYARD
Mailing Address - State:NM
Mailing Address - Zip Code:88036-6216
Mailing Address - Country:US
Mailing Address - Phone:575-537-8831
Mailing Address - Fax:575-537-8886
Practice Address - Street 1:100 CALLE DE CENTRAL
Practice Address - Street 2:
Practice Address - City:FORT BAYARD
Practice Address - State:NM
Practice Address - Zip Code:88036
Practice Address - Country:US
Practice Address - Phone:575-537-8831
Practice Address - Fax:575-537-8886
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NM DEPARTMENT OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5610324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility