Healthcare Provider Details

I. General information

NPI: 1457531360
Provider Name (Legal Business Name): NEW MEXICO FAMILY CHIROPRACTIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 RODEO LN STE D2
SANTA FE NM
87507-5803
US

IV. Provider business mailing address

3600 RODEO LN STE D2
SANTA FE NM
87507-5803
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-0821
  • Fax: 505-984-0168
Mailing address:
  • Phone: 505-984-0821
  • Fax: 505-984-0168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1548
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1545
License Number StateNM

VIII. Authorized Official

Name: DR. JEROME D BUENVIAJE
Title or Position: PRESIDENT/DOCTOR OF CHIROPRACTIC
Credential: D.C.
Phone: 505-984-0821