Healthcare Provider Details

I. General information

NPI: 1568475747
Provider Name (Legal Business Name): JEROME DE CASTRO BUENVIAJE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 RODEO LN SUITE D-2
SANTA FE NM
87507-6400
US

IV. Provider business mailing address

3600 RODEO LN SUITE D-2
SANTA FE NM
87507-6400
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 TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1545
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: