Healthcare Provider Details

I. General information

NPI: 1891975561
Provider Name (Legal Business Name): SANTA FE PEDIATRIC CARDIOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 11/09/2007
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

PO BOX 4760
SANTA FE NM
87502-4760
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-7661
  • Fax: 505-988-5196
Mailing address:
  • Phone: 505-982-7661
  • Fax: 505-988-5196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number1289503
License Number StateNM

VIII. Authorized Official

Name: DR. C. GRANT LA FARGE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 505-982-7661