Provider Demographics
NPI:1992867998
Name:STATE OF NEW MEXICO
Entity Type:Organization
Organization Name:STATE OF NEW MEXICO
Other - Org Name:NM BEHAVIORAL HEALTH INSTITUTE AT LAS VEGAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:JARAMILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-454-2306
Mailing Address - Street 1:3695 HOT SPRINGS BLVD.
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-9549
Mailing Address - Country:US
Mailing Address - Phone:505-454-2100
Mailing Address - Fax:505-454-2130
Practice Address - Street 1:3695 HOT SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-9549
Practice Address - Country:US
Practice Address - Phone:505-454-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF NEW MEXICO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-15
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3035261QM0801X
NM6011283Q00000X
NM5067313M00000X
NM7257322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No283Q00000XHospitalsPsychiatric Hospital
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM600303Medicaid
NMI0126Medicaid
NM96296Medicaid
NM50724Medicaid
NMM1545Medicaid
NMM1545Medicaid