Basic Information
| Provider Information | |||||||||
| NPI: | 1790118099 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA FRONTERA CENTER, INC. DBA LA FRONTERA NEW MEXICO, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 504 W 29TH ST | ||||||||
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| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857133353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208385600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 W GRIGGS AVE | ||||||||
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| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880011234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208385600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2013 | ||||||||
| LastUpdateDate: | 10/10/2013 | ||||||||
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| AuthorizedOfficialLastName: | RANIERI | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 5208385600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | NM | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 18677037 | 05 | NM | MEDICAID |