Provider Demographics
NPI:1922094770
Name:STATE OF NEW MEXICO
Entity type:Organization
Organization Name:STATE OF NEW MEXICO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HOSPITAL ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-347-3400
Mailing Address - Street 1:72 GAIL HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-8116
Mailing Address - Country:US
Mailing Address - Phone:575-347-3400
Mailing Address - Fax:575-347-5177
Practice Address - Street 1:72 GAIL HARRIS AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-8116
Practice Address - Country:US
Practice Address - Phone:575-347-3400
Practice Address - Fax:575-347-5177
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW MEXICO REHABILITATION CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-26
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6026251S00000X, 276400000X, 284300000X, 283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
No251S00000XAgenciesCommunity/Behavioral Health
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No284300000XHospitalsSpecial Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00049528Medicaid
NM28858735Medicaid
NM00000273Medicaid
NM2257806Medicare UPIN