Basic Information
| Provider Information | |||||||||
| NPI: | 1740471036 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. VINCENT HOSPITAL | ||||||||
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| OtherOrganizationName: | OUTPATIENT BEHAVIORAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 SAINT MICHAELS DR | ||||||||
| Address2: | MEDICAL STAFF OFFICE | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058205227 | ||||||||
| FaxNumber: | 5058205645 | ||||||||
| Practice Location | |||||||||
| Address1: | 465 SAINT MICHAELS DR | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058205971 | ||||||||
| FaxNumber: | 5058205645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2007 | ||||||||
| LastUpdateDate: | 08/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | VALDEZ | ||||||||
| AuthorizedOfficialFirstName: | J | ||||||||
| AuthorizedOfficialMiddleName: | ALEX | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 5058205202 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. VINCENT HOSPITAL | ||||||||
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| AuthorizedOfficialCredential: | JD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.