Healthcare Provider Details

I. General information

NPI: 1750717575
Provider Name (Legal Business Name): ENCHANTED FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2013
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4916 4TH ST NW
ALBUQUERQUE NM
87107-3949
US

IV. Provider business mailing address

4916 4TH ST NW
ALBUQUERQUE NM
87107-3949
US

V. Phone/Fax

Practice location:
  • Phone: 505-344-1939
  • Fax: 505-214-5640
Mailing address:
  • Phone: 505-344-1939
  • Fax: 505-214-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberCNP 02228
License Number StateNM

VIII. Authorized Official

Name: MS. MARY LOU SINGLETON
Title or Position: OWNER
Credential: FNP-BC
Phone: 505-573-5134