Healthcare Provider Details

I. General information

NPI: 1528141843
Provider Name (Legal Business Name): SAN JUAN REGIONAL MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E 30TH ST BUILDING 102
FARMINGTON NM
87401-8990
US

IV. Provider business mailing address

PO BOX 844088
DALLAS TX
75284-4088
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-6790
  • Fax: 505-599-4640
Mailing address:
  • Phone: 505-609-2258
  • Fax: 505-609-2259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

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