Provider Demographics
NPI:1508981044
Name:SOUTHWESTERN PRIVATE SERVICES, INC.
Entity Type:Organization
Organization Name:SOUTHWESTERN PRIVATE SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IVY
Authorized Official - Middle Name:
Authorized Official - Last Name:SNIDER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:405-359-2074
Mailing Address - Street 1:408 N AUBURN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5816
Mailing Address - Country:US
Mailing Address - Phone:505-326-6024
Mailing Address - Fax:505-327-6923
Practice Address - Street 1:408 N AUBURN AVE STE B
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5816
Practice Address - Country:US
Practice Address - Phone:505-326-6024
Practice Address - Fax:505-327-6923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6547251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB4365Medicaid