Provider Demographics
NPI:1215925417
Name:FORT BAYARD MEDICAL CENTER
Entity type:Organization
Organization Name:FORT BAYARD MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MDS COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAUREQUI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:505-537-3302
Mailing Address - Street 1:PO BOX 36219
Mailing Address - Street 2:
Mailing Address - City:FT BAYARD
Mailing Address - State:NM
Mailing Address - Zip Code:88036-6219
Mailing Address - Country:US
Mailing Address - Phone:505-537-3302
Mailing Address - Fax:505-537-2161
Practice Address - Street 1:100 CALLE EL CENTRO
Practice Address - Street 2:
Practice Address - City:BAYARD
Practice Address - State:NM
Practice Address - Zip Code:88036
Practice Address - Country:US
Practice Address - Phone:505-537-3302
Practice Address - Fax:505-537-2161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00I0068Medicaid
NM00I0068Medicare ID - Type Unspecified
NM00I0068Medicaid