Healthcare Provider Details

I. General information

NPI: 1609885243
Provider Name (Legal Business Name): SANDIA MOUNTAIN MEDICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 OLD US 66 UNIT 1
EDGEWOOD NM
87015-6784
US

IV. Provider business mailing address

12127B HWY 14 N STE 5
CEDAR CREST NM
87008-9499
US

V. Phone/Fax

Practice location:
  • Phone: 505-286-2396
  • Fax: 505-286-2398
Mailing address:
  • Phone: 505-286-2396
  • Fax: 505-286-2398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: VICTORIA GONZALES
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-832-4434