Healthcare Provider Details

I. General information

NPI: 1487035515
Provider Name (Legal Business Name): SAN JUAN WELLNESS SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E APACHE ST
FARMINGTON NM
87401-6902
US

IV. Provider business mailing address

110 E APACHE ST
FARMINGTON NM
87401-6902
US

V. Phone/Fax

Practice location:
  • Phone: 505-564-7980
  • Fax: 505-564-7956
Mailing address:
  • Phone: 505-564-7980
  • Fax: 505-564-7956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES CROTTY
Title or Position: CEO
Credential:
Phone: 505-564-7980