Healthcare Provider Details

I. General information

NPI: 1194966747
Provider Name (Legal Business Name): CAROLINE KINGSTON MD MPH FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 SAINT MICHAELS DR 1204
SANTA FE NM
87505-7619
US

IV. Provider business mailing address

460 SAINT MICHAELS DR 1204
SANTA FE NM
87505-7619
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-2562
  • Fax: 505-986-0904
Mailing address:
  • Phone: 505-820-2562
  • Fax: 505-986-0904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number97-89
License Number StateNM

VIII. Authorized Official

Name: DR. CAROLINE KINGSTON
Title or Position: DR.
Credential: MD MPH
Phone: 505-820-2562