Healthcare Provider Details

I. General information

NPI: 1942255880
Provider Name (Legal Business Name): PEAK MEDICAL FARMINGTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 W MAPLE ST
FARMINGTON NM
87401-5631
US

IV. Provider business mailing address

806 W MAPLE ST
FARMINGTON NM
87401-5631
US

V. Phone/Fax

Practice location:
  • Phone: 505-325-2910
  • Fax:
Mailing address:
  • Phone: 505-325-2910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1042
License Number StateNM

VIII. Authorized Official

Name: MICHAEL BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4752