Provider Demographics
NPI:1205893377
Name:SIERRA VISTA HOSPITAL 69
Entity type:Organization
Organization Name:SIERRA VISTA HOSPITAL 69
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOMENICA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-894-2111
Mailing Address - Street 1:800 EAST NINTH STREET
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901
Mailing Address - Country:US
Mailing Address - Phone:505-894-2111
Mailing Address - Fax:505-894-7658
Practice Address - Street 1:800 EAST NINTH STREET
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901
Practice Address - Country:US
Practice Address - Phone:505-894-2111
Practice Address - Fax:505-894-7658
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIERRA VISTA HOSPITAL 69
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-01
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM34722751Medicaid