Provider Demographics
NPI:1578075016
Name:STATE OF NEW MEXICO
Entity Type:Organization
Organization Name:STATE OF NEW MEXICO
Other - Org Name:NEW MEXICO REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:GURROLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-347-3410
Mailing Address - Street 1:72 GAIL HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-8116
Mailing Address - Country:US
Mailing Address - Phone:575-347-3400
Mailing Address - Fax:575-347-5177
Practice Address - Street 1:72 GAIL HARRIS ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-8116
Practice Address - Country:US
Practice Address - Phone:575-347-3400
Practice Address - Fax:575-347-5177
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF NEW MEXICO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6026284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0273Medicaid