Provider Demographics
NPI:1063304921
Name:SOUTHERN NEW MEXICO DIABETES OUTREACH
Entity type:Organization
Organization Name:SOUTHERN NEW MEXICO DIABETES OUTREACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-522-0289
Mailing Address - Street 1:506 S MAIN ST STE 700
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1237
Mailing Address - Country:US
Mailing Address - Phone:575-522-0289
Mailing Address - Fax:
Practice Address - Street 1:506 S MAIN ST STE 700
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1237
Practice Address - Country:US
Practice Address - Phone:575-522-0289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-16
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Single Specialty