Basic Information
| Provider Information | |||||||||
| NPI: | 1225407752 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. MARTIN'S HOSPITALITY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 3RD ST NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871021403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057648231 | ||||||||
| FaxNumber: | 5052481351 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 3RD ST NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871021403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057648231 | ||||||||
| FaxNumber: | 5052481351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2015 | ||||||||
| LastUpdateDate: | 09/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | MARQUEZ | ||||||||
| AuthorizedOfficialFirstName: | NEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BH DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5057648231 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 3130 | NM | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | N3938 | 05 | NM | MEDICAID |