Healthcare Provider Details

I. General information

NPI: 1043396377
Provider Name (Legal Business Name): SANTA CLARA HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2006
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STATE ROAD 30 LOS ALAMOS HIGHWAY
ESPANOLA NM
87532
US

IV. Provider business mailing address

RR 5 BOX 446
ESPANOLA NM
87532-8908
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-9421
  • Fax:
Mailing address:
  • Phone: 505-753-9421
  • Fax: 505-753-5039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberH1232
License Number StateNM

VIII. Authorized Official

Name: ROBERT LYON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 505-988-9821