Provider Demographics
NPI:1316940216
Name:PROFESSIONAL HOME HEALTH CARE DE SANTA FE Y LOS ALAMOS
Entity type:Organization
Organization Name:PROFESSIONAL HOME HEALTH CARE DE SANTA FE Y LOS ALAMOS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONWAY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:505-982-8581
Mailing Address - Street 1:10 CALLE MEDICO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4724
Mailing Address - Country:US
Mailing Address - Phone:505-982-8581
Mailing Address - Fax:505-982-0788
Practice Address - Street 1:10 CALLE MEDICO
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4724
Practice Address - Country:US
Practice Address - Phone:505-982-8581
Practice Address - Fax:505-982-0788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6603251E00000X
NM6012 A1251E00000X
NM3068251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ7002Medicaid
NM357657OtherJOINT COMMISSION
NMD2062Medicaid
NM62536711Medicaid