Provider Demographics
NPI:1619150463
Name:SANTA MARIA EL MIRADOR
Entity Type:Organization
Organization Name:SANTA MARIA EL MIRADOR
Other - Org Name:FRATERNAL ORDER OF KNIGHTS TEMPLAR (FOKT)
Other - Org Type:Other Name
Authorized Official - Title/Position:DEPUTY DIRECTOR OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:ELOY
Authorized Official - Middle Name:F
Authorized Official - Last Name:DURAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-428-2004
Mailing Address - Street 1:2041 S PACHECO ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5473
Mailing Address - Country:US
Mailing Address - Phone:505-424-7700
Mailing Address - Fax:505-424-7707
Practice Address - Street 1:2041 S PACHECO ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5473
Practice Address - Country:US
Practice Address - Phone:505-424-7700
Practice Address - Fax:505-424-7707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM02347611007251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM60205512Medicaid