Basic Information
| Provider Information | |||||||||
| NPI: | 1568589653 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. VINCENT HOSPITAL | ||||||||
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| OtherOrganizationName: | ARROYO CHAMISO PEDIATRIC REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 SAINT MICHAELS DR | ||||||||
| Address2: | ATTN. CARLA GOMEZ, PHYSICIAN PRACTICES | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058205227 | ||||||||
| FaxNumber: | 5058205645 | ||||||||
| Practice Location | |||||||||
| Address1: | 2025 SOUTH GALISTEO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875052101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059954901 | ||||||||
| FaxNumber: | 5059896483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 03/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | VALDEZ | ||||||||
| AuthorizedOfficialFirstName: | J | ||||||||
| AuthorizedOfficialMiddleName: | ALEX | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5058205202 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 2251P0200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 225XP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 46433 | 05 | NM | MEDICAID |