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503 Williams St Bldg. #16 Gallup NM 87301-4799 | |
| (505) 722-4383 | |
| (505) 722-2191 |
| Full Name | |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 503 Williams St, Gallup, New Mexico |
| Authorized Official Name and Position | Ellen I Lacayo (EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 5057224383 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 1296 Gallup NM 87305-1296 Ph: (505) 722-4383 | 503 Williams St Bldg. #16 Gallup NM 87301-4799 Ph: (505) 722-4383 |
| NPI Number | 1811048390 |
|---|---|
| Provider Enumeration Date | 01/13/2007 |
| Last Update Date | 08/22/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1811048390 | NPI | - | NPPES |
| E7471 | Medicaid | NM | |
| D0664 | Medicaid | NM |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
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