Healthcare Provider Details

I. General information

NPI: 1295627628
Provider Name (Legal Business Name): THE FOOD DEPOT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2025
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222A SILER RD STE A
SANTA FE NM
87507-3158
US

IV. Provider business mailing address

1222A SILER RD STE A
SANTA FE NM
87507-3158
US

V. Phone/Fax

Practice location:
  • Phone: 505-510-5782
  • Fax: 505-510-5782
Mailing address:
  • Phone: 505-510-5782
  • Fax: 505-510-5782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. JILL DIXON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 505-510-5782