Provider Demographics
NPI:1982795639
Name:STATE OF NEW MEXICO
Entity Type:Organization
Organization Name:STATE OF NEW MEXICO
Other - Org Name:NM DEPARTMENT OF HEALTH TURQUOISE LODGE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAUNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-383-1122
Mailing Address - Street 1:5400 GIBSON BLVD SE
Mailing Address - Street 2:BOX 13
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-4729
Mailing Address - Country:US
Mailing Address - Phone:505-841-8978
Mailing Address - Fax:505-383-1190
Practice Address - Street 1:5400 GIBSON BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-4729
Practice Address - Country:US
Practice Address - Phone:505-841-8978
Practice Address - Fax:505-383-1190
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NM DEPARTMENT OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-27
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NM6306276400000X, 284300000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
No251S00000XAgenciesCommunity/Behavioral Health
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM50454315Medicaid
NM8209332Medicaid
NM08209332Medicaid