Healthcare Provider Details

I. General information

NPI: 1851901920
Provider Name (Legal Business Name): SEAN RUANE X
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 5TH ST STE 100
SANTA FE NM
87505-8750
US

IV. Provider business mailing address

102 N CORONADO AVE
ESPANOLA NM
87532-2700
US

V. Phone/Fax

Practice location:
  • Phone: 505-955-0410
  • Fax:
Mailing address:
  • Phone: 505-692-4473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: