Healthcare Provider Details

I. General information

NPI: 1679149579
Provider Name (Legal Business Name): RYAN TREJO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 LETTON DR
RATON NM
87740-4366
US

IV. Provider business mailing address

PO BOX 28164
SANTA FE NM
87592-8164
US

V. Phone/Fax

Practice location:
  • Phone: 575-383-2065
  • Fax:
Mailing address:
  • Phone: 505-216-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: