Provider Demographics
NPI:1861626145
Name:THOREAU NAVAJO OUTREACH
Entity Type:Organization
Organization Name:THOREAU NAVAJO OUTREACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CLARA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLEDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-862-7415
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:THOREAU
Mailing Address - State:NM
Mailing Address - Zip Code:87323-0547
Mailing Address - Country:US
Mailing Address - Phone:505-862-7415
Mailing Address - Fax:505-862-7635
Practice Address - Street 1:31 FIRST STREET
Practice Address - Street 2:
Practice Address - City:THOREAU
Practice Address - State:NM
Practice Address - Zip Code:87323-0547
Practice Address - Country:US
Practice Address - Phone:505-862-7415
Practice Address - Fax:505-862-7635
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THOREAU NAVAJO OUTREACH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-14
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM684251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55956556Medicaid