Healthcare Provider Details

I. General information

NPI: 1215003801
Provider Name (Legal Business Name): SANTA FE OSTEOPOROSIS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 ASPEN DR SUITE 803A
SANTA FE NM
87505-5459
US

IV. Provider business mailing address

1925 ASPEN DR SUITE 803A
SANTA FE NM
87505-5459
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-4955
  • Fax: 505-983-0491
Mailing address:
  • Phone: 505-983-4955
  • Fax: 505-983-0491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number82161
License Number StateNM

VIII. Authorized Official

Name: DR. AVELINA BARDWELL
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 505-983-4955