Provider Demographics
NPI:1568821015
Name:FORT BAYARD MEDICAL CENTER DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:FORT BAYARD MEDICAL CENTER DEPARTMENT OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:575-537-8745
Mailing Address - Street 1:41 FT BAYARD RD
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:NM
Mailing Address - Zip Code:88026
Mailing Address - Country:US
Mailing Address - Phone:575-537-8745
Mailing Address - Fax:575-537-8897
Practice Address - Street 1:41 FORT BAYARD RD
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:NM
Practice Address - Zip Code:88026-0293
Practice Address - Country:US
Practice Address - Phone:575-537-8745
Practice Address - Fax:575-537-8897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-12
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRSD08058314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility