Healthcare Provider Details

I. General information

NPI: 1629792247
Provider Name (Legal Business Name): ENCHANTMENT CONCIERGE FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6016 KILMER AVE NW
ALBUQUERQUE NM
87120-1410
US

IV. Provider business mailing address

6016 KILMER AVE NW
ALBUQUERQUE NM
87120-1410
US

V. Phone/Fax

Practice location:
  • Phone: 505-681-5287
  • Fax:
Mailing address:
  • Phone: 505-681-5287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRISTA J GURULE
Title or Position: NP-C OWNER
Credential: MSN, APRN, NP-C
Phone: 505-681-5287