Healthcare Provider Details

I. General information

NPI: 1285054445
Provider Name (Legal Business Name): ENRIQUE BUENO CONTRACTOR GENERAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2014
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8052 GROUSE RUN DR
LAS CRUCES NM
88012-9256
US

IV. Provider business mailing address

8052 GROUSE RUN DR
LAS CRUCES NM
88012-9256
US

V. Phone/Fax

Practice location:
  • Phone: 575-202-6972
  • Fax: 575-526-4835
Mailing address:
  • Phone: 575-202-6972
  • Fax: 575-526-4835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number054569
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: