Provider Demographics
NPI:1275842478
Name:CANYON LIGHT INC.
Entity Type:Organization
Organization Name:CANYON LIGHT INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BALDONADO
Authorized Official - Suffix:
Authorized Official - Credentials:LADAC
Authorized Official - Phone:575-430-6913
Mailing Address - Street 1:PO BOX 114
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88311-0114
Mailing Address - Country:US
Mailing Address - Phone:575-437-2453
Mailing Address - Fax:575-443-1504
Practice Address - Street 1:1301 CUBA AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5727
Practice Address - Country:US
Practice Address - Phone:575-437-2453
Practice Address - Fax:575-443-1504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health