Provider Demographics
NPI:1245629187
Name:THE JIM WOOD HOME
Entity type:Organization
Organization Name:THE JIM WOOD HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-649-6686
Mailing Address - Street 1:PO BOX 770
Mailing Address - Street 2:1163 WEST CANAL ST.
Mailing Address - City:HATCH
Mailing Address - State:NM
Mailing Address - Zip Code:87937-0770
Mailing Address - Country:US
Mailing Address - Phone:575-267-1300
Mailing Address - Fax:
Practice Address - Street 1:1163 W. CANAL ST.
Practice Address - Street 2:
Practice Address - City:HATCH
Practice Address - State:NM
Practice Address - Zip Code:87937-0770
Practice Address - Country:US
Practice Address - Phone:575-267-1300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2261261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health