Healthcare Provider Details

I. General information

NPI: 1205957487
Provider Name (Legal Business Name): LA CASA DE BUENA SALUD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 DON PABLO LANE
HONDO NM
88336
US

IV. Provider business mailing address

103 DON PABLO LANE
HONDO NM
88336
US

V. Phone/Fax

Practice location:
  • Phone: 505-653-4830
  • Fax: 505-653-4833
Mailing address:
  • Phone: 505-653-4830
  • Fax: 505-653-4833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNM

VIII. Authorized Official

Name: SEFERINO M MONTANO
Title or Position: CEO
Credential:
Phone: 505-356-6695