Healthcare Provider Details

I. General information

NPI: 1972654580
Provider Name (Legal Business Name): SANTA ANA MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

683 HARKLE RD STE B
SANTA FE NM
87505-4750
US

IV. Provider business mailing address

683 HARKLE RD STE B
SANTA FE NM
87505-4750
US

V. Phone/Fax

Practice location:
  • Phone: 505-954-4422
  • Fax: 505-954-4433
Mailing address:
  • Phone: 505-954-4422
  • Fax: 505-954-4433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberCS00008623
License Number StateNM

VIII. Authorized Official

Name: DR. LEONORA J LOPEZ
Title or Position: OWNER
Credential: MD
Phone: 505-954-4422