Healthcare Provider Details

I. General information

NPI: 1083587612
Provider Name (Legal Business Name): STAFFORD SURGICAL ASSISTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1581 CORTA CANCUN
LOS LUNAS NM
87031-8747
US

IV. Provider business mailing address

1581 CORTA CANCUN
LOS LUNAS NM
87031-8747
US

V. Phone/Fax

Practice location:
  • Phone: 915-433-3922
  • Fax:
Mailing address:
  • Phone: 915-433-3922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name: JEREMY M STAFFORD
Title or Position: CSFA
Credential: CSFA
Phone: 915-433-3922