Healthcare Provider Details

I. General information

NPI: 1124262415
Provider Name (Legal Business Name): SAN JUAN REGIONAL MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2009
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W PINON ST
FARMINGTON NM
87401-5973
US

IV. Provider business mailing address

PO BOX 844088
DALLAS TX
75284-4088
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-2590
  • Fax: 505-609-2595
Mailing address:
  • Phone: 505-609-2258
  • Fax: 505-609-2259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KIM BYRD
Title or Position: ADMINISTRATIVE DIRECTOR OF REIMBURS
Credential:
Phone: 505-609-2258