Healthcare Provider Details

I. General information

NPI: 1528172871
Provider Name (Legal Business Name): SAMUEL C CARPENTER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 04/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 S LAKE ST STE 104
FARMINGTON NM
87401-5659
US

IV. Provider business mailing address

304 S LAKE ST STE 104
FARMINGTON NM
87401-5659
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-3338
  • Fax: 505-566-9213
Mailing address:
  • Phone: 505-327-3338
  • Fax: 505-566-9213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number171
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: