Provider Demographics
NPI:1962569640
Name:OUR LADY OF MOUNT CARMEL
Entity type:Organization
Organization Name:OUR LADY OF MOUNT CARMEL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:505-722-9411
Mailing Address - Street 1:300 MOUNT CARMEL AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-7411
Mailing Address - Country:US
Mailing Address - Phone:505-722-9411
Mailing Address - Fax:
Practice Address - Street 1:300 MOUNT CARMEL AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-7411
Practice Address - Country:US
Practice Address - Phone:505-722-9411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRTC#4372322D00000X, 323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMVNM30195OtherVALUE OPTIONS VENDOR ID
NMNM600391OtherVALUE OPTIONS PROVIDER #
NMRTC#4372OtherSTATE OF NM LICENSE #
NMM1001Medicaid