Provider Demographics
NPI:1073750725
Name:FOUR CORNERS PSYCHIATRIC SERVICES
Entity Type:Organization
Organization Name:FOUR CORNERS PSYCHIATRIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:DIGIOIA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:505-516-0252
Mailing Address - Street 1:3751 N BUTLER AVE
Mailing Address - Street 2:STE 115
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6435
Mailing Address - Country:US
Mailing Address - Phone:505-516-0252
Mailing Address - Fax:
Practice Address - Street 1:3751 N BUTLER AVE
Practice Address - Street 2:STE 115
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6435
Practice Address - Country:US
Practice Address - Phone:505-516-0252
Practice Address - Fax:505-516-0057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-17
Last Update Date:2009-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA1215032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM09057315Medicaid
1154312742OtherNPI