Provider Demographics
NPI:1366484834
Name:HOSPICE SUPPLY OF NEW MEXICO
Entity type:Organization
Organization Name:HOSPICE SUPPLY OF NEW MEXICO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-769-9050
Mailing Address - Street 1:1905 COLONIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-3117
Mailing Address - Country:US
Mailing Address - Phone:505-762-2437
Mailing Address - Fax:505-762-2437
Practice Address - Street 1:2301 MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-9401
Practice Address - Country:US
Practice Address - Phone:505-769-9050
Practice Address - Fax:505-769-9066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM03025316000332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM65477278Medicaid
NMTB61OtherBC BS OF NM
NM=========OtherTRICARE WEST
NM65477278Medicaid