Healthcare Provider Details

I. General information

NPI: 1396277497
Provider Name (Legal Business Name): FNCH SBHC GRANT LOCATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 EASTERDAY DR NE
ALBUQUERQUE NM
87112-5115
US

IV. Provider business mailing address

PO BOX 82610
ALBUQUERQUE NM
87198-2610
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-2481
  • Fax: 505-265-7045
Mailing address:
  • Phone: 505-262-6588
  • Fax: 505-265-7045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MRS. LINDA SON STONE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 505-262-6588