Basic Information
| Provider Information | |||||||||
| NPI: | 1598869521 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW MEXICO VA HEALTH CARE SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5741 OSUNA RD NE | ||||||||
| Address2: | APT. 1050 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871092567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058306907 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 SAN PEDRO DR SE | ||||||||
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| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871085153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052651711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROMO | ||||||||
| AuthorizedOfficialFirstName: | MANUEL | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 5052651711 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I-0159 | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | I-0159 | 01 | NM | SOCIAL WORK | OTHER |