Healthcare Provider Details

I. General information

NPI: 1568821015
Provider Name (Legal Business Name): FORT BAYARD MEDICAL CENTER DEPARTMENT OF HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 02/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 FORT BAYARD RD
SANTA CLARA NM
88026-0293
US

IV. Provider business mailing address

41 FT BAYARD RD
SANTA CLARA NM
88026
US

V. Phone/Fax

Practice location:
  • Phone: 575-537-8745
  • Fax: 575-537-8897
Mailing address:
  • Phone: 575-537-8745
  • Fax: 575-537-8897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberRSD08058
License Number StateNM

VIII. Authorized Official

Name: MR. MARK BAILEY
Title or Position: DIRECTOR OF PHARMACY
Credential: RPH
Phone: 575-537-8745