Healthcare Provider Details

I. General information

NPI: 1063531341
Provider Name (Legal Business Name): VILLAGE OF EAGLE NEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 09/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 TOMBOY DR.
EAGLE NEST NM
87718
US

IV. Provider business mailing address

74 TOMBOY DR.
EAGLE NEST NM
87718
US

V. Phone/Fax

Practice location:
  • Phone: 505-377-0663
  • Fax:
Mailing address:
  • Phone: 505-377-0663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State

VIII. Authorized Official

Name: MR. WAYNE BAKER
Title or Position: BILLING AGENT
Credential:
Phone: 505-376-2939