Provider Demographics
NPI:1275909871
Name:REGENTS OF NEW MEXICO STATE UNIVERSITY
Entity Type:Organization
Organization Name:REGENTS OF NEW MEXICO STATE UNIVERSITY
Other - Org Name:NMSU HEARING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAS-PROVANCE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD CCC-SLP
Authorized Official - Phone:575-646-2402
Mailing Address - Street 1:3600 ARROWHEAD RD
Mailing Address - Street 2:BUILDING 08
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-5129
Mailing Address - Country:US
Mailing Address - Phone:575-674-0593
Mailing Address - Fax:
Practice Address - Street 1:3600 ARROWHEAD DR
Practice Address - Street 2:BLDG 08
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011
Practice Address - Country:US
Practice Address - Phone:575-674-0593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6545231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM90123280Medicaid