Healthcare Provider Details

I. General information

NPI: 1275836231
Provider Name (Legal Business Name): SAN JON SCHOOL BASED HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2010
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7TH AND ELM STREET
SAN JON NM
88434
US

IV. Provider business mailing address

PO BOX 5
SAN JON NM
88434-0005
US

V. Phone/Fax

Practice location:
  • Phone: 575-576-2273
  • Fax: 575-576-2273
Mailing address:
  • Phone: 575-576-2273
  • Fax: 575-576-2273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. GARY SALAZAR
Title or Position: SUPERINTENDENT OF SCHOOLS
Credential:
Phone: 575-576-2467