Healthcare Provider Details

I. General information

NPI: 1609041706
Provider Name (Legal Business Name): SAN MIGUEL HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 LEGION DR
LAS VEGAS NM
87701-4808
US

IV. Provider business mailing address

104 LEGION DR
LAS VEGAS NM
87701-4808
US

V. Phone/Fax

Practice location:
  • Phone: 505-426-3500
  • Fax:
Mailing address:
  • Phone: 505-426-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE BREWER
Title or Position: DIRECTOR
Credential:
Phone: 877-892-9813