Provider Demographics
NPI:1639382542
Name:NMDOH FAMILY INFANT TODDLER PROGRAM
Entity Type:Organization
Organization Name:NMDOH FAMILY INFANT TODDLER PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EARLY CHILDHOOD COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-827-2578
Mailing Address - Street 1:1190 SAINT FRANCIS DRIVE
Mailing Address - Street 2:PO BOX 26110
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-6110
Mailing Address - Country:US
Mailing Address - Phone:505-827-1711
Mailing Address - Fax:505-827-2455
Practice Address - Street 1:1190 SAINT FRANCIS DRIVE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87502-6110
Practice Address - Country:US
Practice Address - Phone:505-827-1711
Practice Address - Fax:505-827-2455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health