Provider Demographics
NPI:1750418281
Name:REGION IX DEVELOPMENTAL SERVICES
Entity type:Organization
Organization Name:REGION IX DEVELOPMENTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GLADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-257-3105
Mailing Address - Street 1:1400 SUDDERTH DR
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-6103
Mailing Address - Country:US
Mailing Address - Phone:505-257-2368
Mailing Address - Fax:505-257-1033
Practice Address - Street 1:1400 SUDDERTH DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6103
Practice Address - Country:US
Practice Address - Phone:505-257-3105
Practice Address - Fax:505-257-1033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM07665.0070405251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000E7442Medicaid