Healthcare Provider Details

I. General information

NPI: 1912020694
Provider Name (Legal Business Name): TOWN OF ESTANCIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HIGHLAND AVE.
ESTANCIA NM
87016-9998
US

IV. Provider business mailing address

PO BOX 641880
OMAHA NE
68164-7880
US

V. Phone/Fax

Practice location:
  • Phone: 505-384-4338
  • Fax: 505-384-5351
Mailing address:
  • Phone: 402-572-4019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License NumberNMPRC29222
License Number StateNM

VIII. Authorized Official

Name: LESTER E. GARY
Title or Position: FIRE CHIEF
Credential: PARAMEDIC
Phone: 505-384-4338