Basic Information
| Provider Information | |||||||||
| NPI: | 1801460001 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | JOSE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CASE MANGER | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 385 CALLE DE ALEGRA STE A | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755261105 | ||||||||
| FaxNumber: | 5755244266 | ||||||||
| Practice Location | |||||||||
| Address1: | 2625 MCNUTT RD STE B | ||||||||
| Address2: | |||||||||
| City: | SUNLAND PARK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880639608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755896540 | ||||||||
| FaxNumber: | 5755895864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2021 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | NM | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.