Provider Demographics
NPI:1265007496
Name:SOLID SOCIETY OF NEW MEXICO CORP
Entity Type:Organization
Organization Name:SOLID SOCIETY OF NEW MEXICO CORP
Other - Org Name:SOLID SOCIETY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:505-758-7200
Mailing Address - Street 1:1933 SAN MATEO BLVD NE # 191
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5146
Mailing Address - Country:US
Mailing Address - Phone:505-758-7200
Mailing Address - Fax:
Practice Address - Street 1:609 GOLD AVE SW STE 1F
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3119
Practice Address - Country:US
Practice Address - Phone:505-758-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-20
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM40136728Medicaid