Healthcare Provider Details

I. General information

NPI: 1215037379
Provider Name (Legal Business Name): LA CASA DE BUENA SALUD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 SOUTH GRAND AVENUE
ROSWELL NM
88201
US

IV. Provider business mailing address

PO BOX 843
PORTALES NM
88130
US

V. Phone/Fax

Practice location:
  • Phone: 505-623-3255
  • Fax: 505-625-9901
Mailing address:
  • Phone: 505-356-6695
  • Fax: 505-356-5948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number6460
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: SEFERINO M MONTANO
Title or Position: CEO
Credential:
Phone: 505-356-6695