Provider Demographics
NPI:1609816206
Name:MESCALERO CARE CENTER
Entity Type:Organization
Organization Name:MESCALERO CARE CENTER
Other - Org Name:MESCALERO CARE CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MERLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:KAYDAHZINNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-464-4802
Mailing Address - Street 1:P.O. BOX 359
Mailing Address - Street 2:454 LIPAN AVE
Mailing Address - City:MESCALERO
Mailing Address - State:NM
Mailing Address - Zip Code:88340
Mailing Address - Country:US
Mailing Address - Phone:575-464-4802
Mailing Address - Fax:575-464-4808
Practice Address - Street 1:454 LIPAN AVE
Practice Address - Street 2:
Practice Address - City:MESCALERO
Practice Address - State:NM
Practice Address - Zip Code:88340
Practice Address - Country:US
Practice Address - Phone:505-464-4802
Practice Address - Fax:505-464-4808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3127261QE0700X
NM2026314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM67601081Medicaid
NM33531846Medicaid
NM33531846Medicaid
NM67601081Medicaid