Provider Demographics
NPI:1407057607
Name:STATE OF NEW MEXICO
Entity Type:Organization
Organization Name:STATE OF NEW MEXICO
Other - Org Name:NEW MEXICO BEHAVIORAL HEALTH INSTITUE AT LAS VEGAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:JARAMILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-454-2306
Mailing Address - Street 1:3695 HOT SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-9549
Mailing Address - Country:US
Mailing Address - Phone:505-454-2100
Mailing Address - Fax:
Practice Address - Street 1:3695 HOT SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-9549
Practice Address - Country:US
Practice Address - Phone:505-454-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM32D0653275291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM52431Medicaid
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