Healthcare Provider Details

I. General information

NPI: 1396716643
Provider Name (Legal Business Name): SAN MIGUEL HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 LEGION DR
LAS VEGAS NM
87701-4804
US

IV. Provider business mailing address

104 LEGION DR
LAS VEGAS NM
87701-4804
US

V. Phone/Fax

Practice location:
  • Phone: 505-426-3500
  • Fax: 505-454-9502
Mailing address:
  • Phone: 505-426-3500
  • Fax: 505-454-9502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number3005
License Number StateNM

VIII. Authorized Official

Name: RANDY MICHAEL COOPER
Title or Position: SVP FINANCE OP/AUTHORIZED OFFICIAL
Credential:
Phone: 615-221-3840