Healthcare Provider Details

I. General information

NPI: 1205010881
Provider Name (Legal Business Name): AGNES MARTINEZ FAMILY HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STATE HIGHWAY 518 MILE MARKER 29
MORA NM
87732-0185
US

IV. Provider business mailing address

PO BOX 185
MORA NM
87732-0185
US

V. Phone/Fax

Practice location:
  • Phone: 505-387-5503
  • Fax: 505-387-5502
Mailing address:
  • Phone: 505-387-5503
  • Fax: 505-387-5502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number363LF0000X
License Number StateNM

VIII. Authorized Official

Name: MRS. MARY BUNKER
Title or Position: OWNER
Credential: CNP
Phone: 505-387-5503