Healthcare Provider Details

I. General information

NPI: 1467649806
Provider Name (Legal Business Name): VILLAGE OF ANGEL FIRE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 08/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 N ANGEL FIRE ROAD
ANGEL FIRE NM
87710
US

IV. Provider business mailing address

PO BOX 610
ANGEL FIRE NM
87710-0610
US

V. Phone/Fax

Practice location:
  • Phone: 505-377-3347
  • Fax: 505-377-6098
Mailing address:
  • Phone: 505-377-3347
  • Fax: 505-377-6098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License NumberG53792
License Number StateNM

VIII. Authorized Official

Name: MR. ORLANDO SANDOVAL
Title or Position: FIRE DEPARTMENT CHIEF
Credential:
Phone: 505-377-3347