Provider Demographics
NPI:1386870137
Name:DISMAS HOUSE NM INC.
Entity type:Organization
Organization Name:DISMAS HOUSE NM INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RUSTY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:REVEREND
Authorized Official - Phone:505-343-0746
Mailing Address - Street 1:PO BOX 6101
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87197-6101
Mailing Address - Country:US
Mailing Address - Phone:505-343-0746
Mailing Address - Fax:505-345-4513
Practice Address - Street 1:701 CANDELARIA RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-2407
Practice Address - Country:US
Practice Address - Phone:505-343-0746
Practice Address - Fax:505-345-4513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility