Provider Demographics
NPI:1821203217
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:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-424-7700
Mailing Address - Street 1:10 A VAN NU PO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508
Mailing Address - Country:US
Mailing Address - Phone:505-424-7700
Mailing Address - Fax:505-395-7452
Practice Address - Street 1:10 A VAN NU PO
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508
Practice Address - Country:US
Practice Address - Phone:505-424-7700
Practice Address - Fax:505-395-7452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2023-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM02-3476-110-07251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMM1474Medicaid
NMM2337Medicaid