Healthcare Provider Details

I. General information

NPI: 1013086685
Provider Name (Legal Business Name): DEVINE FAMILY HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 APACHE PLUME RD
LOS LUNAS NM
87031-9545
US

IV. Provider business mailing address

PO BOX 907
BELEN NM
87002-0907
US

V. Phone/Fax

Practice location:
  • Phone: 505-859-0686
  • Fax: 505-565-2835
Mailing address:
  • Phone: 505-859-0686
  • Fax: 505-565-2835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberR48132
License Number StateNM

VIII. Authorized Official

Name: MS. MARY J DEVINE
Title or Position: OWNER
Credential: CFNP
Phone: 505-859-0686