Provider Demographics
NPI:1619072915
Name:SAN VICENTE HOME HEALTH LLC
Entity Type:Organization
Organization Name:SAN VICENTE HOME HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:D
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:505-538-0912
Mailing Address - Street 1:PO BOX 2307
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88062-2307
Mailing Address - Country:US
Mailing Address - Phone:505-538-0912
Mailing Address - Fax:505-538-0917
Practice Address - Street 1:200 N ARIZONA ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-4963
Practice Address - Country:US
Practice Address - Phone:505-538-0912
Practice Address - Fax:505-538-0917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6549251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM327146Medicare ID - Type UnspecifiedHOME HEALTH CARE PROVIDER