Provider Demographics
NPI:1679573778
Name:SAN JUAN REGIONAL REHABILITATION HOSPITAL, INC.
Entity type:Organization
Organization Name:SAN JUAN REGIONAL REHABILITATION HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE
Authorized Official - Phone:505-609-6110
Mailing Address - Street 1:525 S. SCHWARTZ
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5955
Mailing Address - Country:US
Mailing Address - Phone:505-609-2625
Mailing Address - Fax:505-327-6562
Practice Address - Street 1:525 S. SCHWARTZ
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5955
Practice Address - Country:US
Practice Address - Phone:505-609-2625
Practice Address - Fax:505-327-6562
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN JUAN REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6578283X00000X
NM283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB2236Medicaid
NM323029Medicare Oscar/Certification
323029Medicare Oscar/Certification