Healthcare Provider Details

I. General information

NPI: 1962849950
Provider Name (Legal Business Name): ENCHANTMENT HEALTHCARE,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2013
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 MAIN ST NE SUITE A
LOS LUNAS NM
87031-7559
US

IV. Provider business mailing address

106 MAIN ST NE SUITE A
LOS LUNAS NM
87031-7559
US

V. Phone/Fax

Practice location:
  • Phone: 505-565-0070
  • Fax: 505-565-0978
Mailing address:
  • Phone: 505-565-0070
  • Fax: 505-565-0978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number84-288
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2005-0037
License Number StateNM

VIII. Authorized Official

Name: MRS. MONIQUE NICOLE SISNEROS
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-615-8336