Healthcare Provider Details

I. General information

NPI: 1134011604
Provider Name (Legal Business Name): SALVADOR BLANCO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 01/12/2026
Certification Date: 01/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6569 WINDING RIDGE LOOP
SANTA FE NM
87507-3191
US

IV. Provider business mailing address

6569 WINDING RIDGE LOOP
SANTA FE NM
87507-3191
US

V. Phone/Fax

Practice location:
  • Phone: 505-501-5953
  • Fax:
Mailing address:
  • Phone: 505-501-5953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number57188
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: