Provider Demographics
NPI:1194886499
Name:NEW MEXICO DEPARTMENT OF HEALTH
Entity type:Organization
Organization Name:NEW MEXICO DEPARTMENT OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LINE II MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:GIFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-232-5712
Mailing Address - Street 1:7905 MARBLE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7886
Mailing Address - Country:US
Mailing Address - Phone:505-232-5712
Mailing Address - Fax:505-222-0933
Practice Address - Street 1:7905 MARBLE AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7886
Practice Address - Country:US
Practice Address - Phone:505-222-0900
Practice Address - Fax:505-222-0933
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF NEW MEXICO, DOH, DDSD, ASB
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-12
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000D1977Medicaid