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Organization subpart
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Provider details

NPI number
Authorized official
ONECIMO MIRABAL (CHIEF EXECUTIVE OFFICER)
(505) 804-2899
Entity
Organization

Contact information

Practice address
3080 DESERT SAGE AVE SW, LOS LUNAS, NM 87031-6577
(505) 804-2899
Mailing address
3080 DESERT SAGE AVE SW, LOS LUNAS, NM 87031-6577
(505) 804-2899

Taxonomy

Speciality
Code
Description
License number
State
261QC1500X
Community Health Clinic/Center
Primary
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

Other

Enumeration date
06/13/2024
Last updated
01/31/2025
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