Provider Demographics
NPI:1073529624
Name:STATE OF NEW MEXICO
Entity Type:Organization
Organization Name:STATE OF NEW MEXICO
Other - Org Name:NEW MEXICO STATE VETERANS HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:RICHTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-894-4216
Mailing Address - Street 1:992 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-3198
Mailing Address - Country:US
Mailing Address - Phone:575-894-4200
Mailing Address - Fax:575-894-4291
Practice Address - Street 1:992 S BROADWAY
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-3198
Practice Address - Country:US
Practice Address - Phone:575-894-4200
Practice Address - Fax:575-894-4291
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF NEW MEXICO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-01
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM32D0693149291U00000X
NM5087291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM52367Medicaid
856000566Medicare PIN
NM52367Medicaid