Healthcare Provider Details

I. General information

NPI: 1235026261
Provider Name (Legal Business Name): FENTON FAMILY MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 06/23/2025
Certification Date: 06/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 E ROOSEVELT AVE
GRANTS NM
87020-2113
US

IV. Provider business mailing address

824 HOUSTON AVE
GRANTS NM
87020-3017
US

V. Phone/Fax

Practice location:
  • Phone: 505-685-1347
  • Fax:
Mailing address:
  • Phone: 505-315-1162
  • Fax: 866-271-1136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DANIEL FENTON
Title or Position: OWNER
Credential:
Phone: 505-315-1162