Provider Demographics
NPI:1649310749
Name:TAOS GROUP HOME, INC.
Entity type:Organization
Organization Name:TAOS GROUP HOME, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DEPAULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-751-7037
Mailing Address - Street 1:314 DON FERNANDO ST
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-5953
Mailing Address - Country:US
Mailing Address - Phone:575-751-7037
Mailing Address - Fax:575-751-3010
Practice Address - Street 1:314 DON FERNANDO ST
Practice Address - Street 2:POB 2360
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5953
Practice Address - Country:US
Practice Address - Phone:575-751-7037
Practice Address - Fax:575-751-3010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0752261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM84472855Medicaid
NMJ6668Medicaid
NMM1866Medicaid
NM11034254Medicaid
NMR8496Medicaid