Healthcare Provider Details

I. General information

NPI: 1265475230
Provider Name (Legal Business Name): FOUR CORNERS RADIOLOGY ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W. MAPLE
FARMINGTON NM
87401
US

IV. Provider business mailing address

PO BOX 2019
FARMINGTON NM
87499-2019
US

V. Phone/Fax

Practice location:
  • Phone: 505-325-1572
  • Fax:
Mailing address:
  • Phone: 505-325-1572
  • Fax: 505-327-4887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DANYLE CONNER
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-325-1572