Healthcare Provider Details

I. General information

NPI: 1265721427
Provider Name (Legal Business Name): LA CASA DE BUENA SALUD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 03/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W WILSHIRE BLVD SUITE A
ROSWELL NM
88201-0627
US

IV. Provider business mailing address

200 W WILSHIRE BLVD SUITE A
ROSWELL NM
88201-0627
US

V. Phone/Fax

Practice location:
  • Phone: 575-623-3255
  • Fax:
Mailing address:
  • Phone: 575-623-3255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License NumberPENDING
License Number StateNM

VIII. Authorized Official

Name: SEFERINO M MONTANO
Title or Position: CEO
Credential:
Phone: 575-356-6695