Healthcare Provider Details

I. General information

NPI: 1679211791
Provider Name (Legal Business Name): FAMILY FOOT HEALTH SPECIALISTS OF FARMINGTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 N BUTLER AVE STE 14-102
FARMINGTON NM
87401-0815
US

IV. Provider business mailing address

4801 N BUTLER AVE STE 14-102
FARMINGTON NM
87401-0815
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-3650
  • Fax: 505-327-2350
Mailing address:
  • Phone: 505-327-3650
  • Fax: 505-327-2350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. DENISE DORNER
Title or Position: PODIATRIST
Credential: DPM
Phone: 505-860-4919