Basic Information
| Provider Information | |||||||||
| NPI: | 1538555040 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA CASA DE BUENA SALUD INC | ||||||||
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| OtherOrganizationName: | LA CASA COMMUNITY BEHAVIORAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 W FIR ST | ||||||||
| Address2: | |||||||||
| City: | PORTALES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 881305703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753566695 | ||||||||
| FaxNumber: | 5753565948 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 E MESCALERO RD | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882016542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756256130 | ||||||||
| FaxNumber: | 5756233325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2015 | ||||||||
| LastUpdateDate: | 04/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | MONTANO | ||||||||
| AuthorizedOfficialFirstName: | SEFERINO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5753566695 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | NM | Y | Agencies | Community/Behavioral Health |
No ID Information.