Provider Demographics
NPI:1396944211
Name:SANTO DOMINGO BEHAVIORAL HEALTH PROGRAM
Entity type:Organization
Organization Name:SANTO DOMINGO BEHAVIORAL HEALTH PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LUCIANO
Authorized Official - Middle Name:
Authorized Official - Last Name:CALABAZA
Authorized Official - Suffix:
Authorized Official - Credentials:LADAC
Authorized Official - Phone:505-465-2733
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:SANTO DOMINGO PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87052-0130
Mailing Address - Country:US
Mailing Address - Phone:505-465-2733
Mailing Address - Fax:
Practice Address - Street 1:10 TESUQUE ST
Practice Address - Street 2:
Practice Address - City:SANTO DOMINGO PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87052-9998
Practice Address - Country:US
Practice Address - Phone:505-465-2733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health