Healthcare Provider Details

I. General information

NPI: 1164603619
Provider Name (Legal Business Name): SANTA TERESA OCCMED CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5055 MCNUTT RD
SANTA TERESA NM
88008-9442
US

IV. Provider business mailing address

5055 MCNUTT RD
SANTA TERESA NM
88008-9442
US

V. Phone/Fax

Practice location:
  • Phone: 505-589-5005
  • Fax:
Mailing address:
  • Phone: 505-589-5005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. REBECCA L. AYERS
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 915-842-0504