Provider Demographics
NPI:1205219771
Name:DISMAS HOUSE
Entity Type:Organization
Organization Name:DISMAS HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMMUNITY SERVICE WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GIVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-343-0746
Mailing Address - Street 1:PO BOX 6101
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87197-6101
Mailing Address - Country:US
Mailing Address - Phone:505-343-0746
Mailing Address - Fax:505-345-4513
Practice Address - Street 1:701 CANDELARIA
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-343-0746
Practice Address - Fax:505-345-4513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNPI#1902918055320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN3938Medicaid