Provider Demographics
NPI:1982730669
Name:STATE OF NEW MEXICO
Entity type:Organization
Organization Name:STATE OF NEW MEXICO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:BAYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-537-8606
Mailing Address - Street 1:PO BOX 293
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:NM
Mailing Address - Zip Code:88026-0293
Mailing Address - Country:US
Mailing Address - Phone:575-537-8600
Mailing Address - Fax:575-537-3753
Practice Address - Street 1:41 FORT BAYARD ROAD
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:NM
Practice Address - Zip Code:88026
Practice Address - Country:US
Practice Address - Phone:575-537-8600
Practice Address - Fax:575-537-8869
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NM DEPARTMENT OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-26
Last Update Date:2024-12-12
Deactivation Date:2017-02-13
Deactivation Code:
Reactivation Date:2017-02-22
Provider Licenses
StateLicense IDTaxonomies
NM5011282E00000X, 314000000X
313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM014OtherMOLINA HEALTHCARE
NM51972786Medicaid
NM50716Medicaid
NMNM00N526OtherBLUE CROSS BLUE SHIELD
NM3204574OtherN.A.B.P. IDENTIFIER #
NMAL3362097OtherD.E. A. IDENTIFIER NUMBER
2250207Medicare PIN
NMNM00N526OtherBLUE CROSS BLUE SHIELD
2250207Medicare PIN
NMNM00N526OtherBLUE CROSS BLUE SHIELD