Healthcare Provider Details

I. General information

NPI: 1740408756
Provider Name (Legal Business Name): VILLAGE OF SAN JON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 E. ELM
SAN JON NM
88434
US

IV. Provider business mailing address

10802 FARNAM DR
OMAHA NE
68154-3237
US

V. Phone/Fax

Practice location:
  • Phone: 505-576-2922
  • Fax: 505-576-2722
Mailing address:
  • Phone: 877-218-4392
  • Fax: 877-343-0131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number02690
License Number StateNM

VIII. Authorized Official

Name: MR. DEBBIE L. STONER
Title or Position: OFFICIAL
Credential: EMT-I
Phone: 575-403-8463