MEDICARE: VILLAGE OF SAN JON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3416L0300X	Land Ambulance	02690	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	02690	OTHER	NM	STATE LICENSE

General Provider Information

NPI Number	:	1740408756
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLAGE OF SAN JON

Provider Business Mailing Address
First Line	:	10802 FARNAM DR
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68154-3237
Country	:	US
Telephone Number	:	877-218-4392
Fax Number	:	877-343-0131

Provider Business Practice Location Address
First Line	:	414 E. ELM
Second Line	:
City	:	SAN JON
State	:	NM
Zip	:	88434
Country	:	US
Telephone Number	:	505-576-2922
Fax Number	:	505-576-2722

Authorized Official
Title or Position	:	OFFICIAL
Name	:	MR. DEBBIE L. STONER
Credential	:	EMT-I
Telephone Number	:	575-403-8463

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	08/21/2023

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Directions to “VILLAGE OF SAN JON ” Practice Location

Language	Start Address	Practice Location

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