| Four Corners Detox Recovery | |
|
2105 Hasler Valley Rd Gallup NM 87305 | |
| (505) 471-9856 | |
| Not Available |
| Full Name | Four Corners Detox Recovery |
|---|---|
| Speciality | Substance Abuse Rehabilitation Facility |
| Location | 2105 Hasler Valley Rd, Gallup, New Mexico |
| Authorized Official Name and Position | Lou Duran (CREDENTIALING AND BILLING) |
| Authorized Official Contact | 5052703966 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Four Corners Detox Recovery 2504 Camino Entrada Santa Fe NM 87507-4851 Ph: (505) 471-4985 | Four Corners Detox Recovery 2105 Hasler Valley Rd Gallup NM 87305 Ph: (505) 471-9856 |
| NPI Number | 1033716972 |
|---|---|
| Provider Enumeration Date | 10/05/2020 |
| Last Update Date | 11/25/2023 |
| Certification Date | 11/25/2023 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1033716972 | NPI | - | NPPES |
| 82536716 | Medicaid | NM |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TP2701X | Psychologist - Group Psychotherapy | (* (Not Available)) | Secondary |
| 324500000X | Substance Abuse Rehabilitation Facility | (* (Not Available)) | Primary |
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