Healthcare Provider Details

I. General information

NPI: 1144310871
Provider Name (Legal Business Name): SANTA FE TRAIL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 WAVERLY AVE
TRINIDAD CO
81082-2039
US

IV. Provider business mailing address

PO BOX 860
TRINIDAD CO
81082-0860
US

V. Phone/Fax

Practice location:
  • Phone: 505-647-8366
  • Fax: 505-647-8381
Mailing address:
  • Phone: 505-647-8366
  • Fax: 505-647-8381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BETTY WITHINGTON
Title or Position: PERSONAL REP.
Credential:
Phone: 505-647-8366