Healthcare Provider Details

I. General information

NPI: 1629513791
Provider Name (Legal Business Name): CARLOS TREVINO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 E PINE ST
DEMING NM
88030-7009
US

IV. Provider business mailing address

1021 E PINE ST
DEMING NM
88030-7009
US

V. Phone/Fax

Practice location:
  • Phone: 575-546-6746
  • Fax: 575-546-6748
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00008647
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: