Healthcare Provider Details

I. General information

NPI: 1508219916
Provider Name (Legal Business Name): SAN JUAN REGIONAL MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N CHURCH ST STE C
BLOOMFIELD NM
87413-5754
US

IV. Provider business mailing address

PO BOX 6210
FARMINGTON NM
87499-6210
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-6675
  • Fax: 505-609-6579
Mailing address:
  • Phone: 505-609-2258
  • Fax: 505-609-2259

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: KAREN S MILLER
Title or Position: CFO
Credential:
Phone: 505-609-6114