Provider Demographics
NPI:1619398096
Name:SMITH, HENRY SOTO (FOSTER PARENT)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:SOTO
Last Name:SMITH
Suffix:
Gender:M
Credentials:FOSTER PARENT
Other - Prefix:
Other - First Name:HANK
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:385 CALLE DE ALEGRA STE A
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3423
Mailing Address - Country:US
Mailing Address - Phone:575-526-1105
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:1626 E LAS CRUCES AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-2635
Practice Address - Country:US
Practice Address - Phone:575-621-9979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-02
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM74481Medicaid