Provider Demographics
NPI:1942365176
Name:INTERFAITH-LEAP INC.
Entity Type:Organization
Organization Name:INTERFAITH-LEAP INC.
Other - Org Name:INTERFAITH-LEAP INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXCUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:ETC
Authorized Official - Phone:505-351-2163
Mailing Address - Street 1:PO BOX 3220
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:NM
Mailing Address - Zip Code:87533-3220
Mailing Address - Country:US
Mailing Address - Phone:505-351-2163
Mailing Address - Fax:505-351-2446
Practice Address - Street 1:JOHN HYSON DR.
Practice Address - Street 2:
Practice Address - City:CHIMAYO
Practice Address - State:NM
Practice Address - Zip Code:87522
Practice Address - Country:US
Practice Address - Phone:505-351-2163
Practice Address - Fax:505-351-2446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM600922302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization