Healthcare Provider Details

I. General information

NPI: 1700090453
Provider Name (Legal Business Name): JOHN MICHAEL STEWART B.U.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E AZTEC AVE
GALLUP NM
87301-6256
US

IV. Provider business mailing address

313 STAGECOACH CIR
GALLUP NM
87301-6792
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-3377
  • Fax: 505-722-5622
Mailing address:
  • Phone: 505-863-3377
  • Fax: 505-722-5622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0076911
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: