Healthcare Provider Details

I. General information

NPI: 1013202969
Provider Name (Legal Business Name): EL CENTRO FAMILY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2011
Last Update Date: 06/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N. CORONADO STREET
ESPANOLA NM
87532-0158
US

IV. Provider business mailing address

620 N. CORONADO STREET
ESPANOLA NM
87532-0158
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-7218
  • Fax: 505-753-5815
Mailing address:
  • Phone: 505-753-7218
  • Fax: 505-753-5815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-01740
License Number StateNM

VIII. Authorized Official

Name: MRS. LUCILLE MONTOYA
Title or Position: CHIEF OPERATIONS OFFICER
Credential:
Phone: 505-753-7218