Healthcare Provider Details

I. General information

NPI: 1598028268
Provider Name (Legal Business Name): FELIX OLMEDO GONZALES JR. ORDAINED PASTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 E. ARIZONA ST.
LAS CRUCES NM
88001
US

IV. Provider business mailing address

3260 VENUS ST #41
LAS CRUCES NM
88012-7753
US

V. Phone/Fax

Practice location:
  • Phone: 575-386-2944
  • Fax:
Mailing address:
  • Phone: 575-386-2944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberNOT LICENSED
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: