Provider Demographics
NPI:1962569640
Name:OUR LADY OF MOUNT CARMEL
Entity type:Organization
Organization Name:OUR LADY OF MOUNT CARMEL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:505-722-9411
Mailing Address - Street 1:300 MOUNT CARMEL AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-7411
Mailing Address - Country:US
Mailing Address - Phone:505-722-9411
Mailing Address - Fax:
Practice Address - Street 1:300 MOUNT CARMEL AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-7411
Practice Address - Country:US
Practice Address - Phone:505-722-9411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRTC#4372322D00000X, 323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Not Answered323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMVNM30195OtherVALUE OPTIONS VENDOR ID
NMNM600391OtherVALUE OPTIONS PROVIDER #
NMRTC#4372OtherSTATE OF NM LICENSE #
NMM1001Medicaid