Provider Demographics
NPI:1548452949
Name:TRUST IN GOD REHABILITATION
Entity type:Organization
Organization Name:TRUST IN GOD REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-758-3879
Mailing Address - Street 1:P.O. BOX 6499
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87511
Mailing Address - Country:US
Mailing Address - Phone:575-758-3879
Mailing Address - Fax:
Practice Address - Street 1:489 BLUEBERRY HILL ROAD
Practice Address - Street 2:
Practice Address - City:EL PRADO
Practice Address - State:NM
Practice Address - Zip Code:87529
Practice Address - Country:US
Practice Address - Phone:575-758-3879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM06217104100000X
NMCU00010276324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty