Healthcare Provider Details

I. General information

NPI: 1780917757
Provider Name (Legal Business Name): JOHN BUFFINGTON SA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 PORR DR
RUIDOSO NM
88345
US

IV. Provider business mailing address

PO BOX 28220
SANTA FE NM
87592
US

V. Phone/Fax

Practice location:
  • Phone: 575-630-0571
  • Fax: 575-630-0574
Mailing address:
  • Phone: 505-471-5006
  • Fax: 505-820-9220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0068182
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: