Provider Demographics
NPI:1497872550
Name:NEW VISION GROUP HOME
Entity Type:Organization
Organization Name:NEW VISION GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-769-2142
Mailing Address - Street 1:919 RENCHER ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-5858
Mailing Address - Country:US
Mailing Address - Phone:505-769-2142
Mailing Address - Fax:505-769-2161
Practice Address - Street 1:919 RENCHER ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-5858
Practice Address - Country:US
Practice Address - Phone:505-769-2142
Practice Address - Fax:505-769-2161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM04937261Medicaid