Healthcare Provider Details

I. General information

NPI: 1609270891
Provider Name (Legal Business Name): PHYLLIS NADINE GONZALES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2014
Last Update Date: 03/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 WASHINGTON AVE
SANTA FE NM
87501-1926
US

IV. Provider business mailing address

121 CAMINO ENCANTADO
SANTA FE NM
87501-1039
US

V. Phone/Fax

Practice location:
  • Phone: 505-946-7677
  • Fax: 505-986-1569
Mailing address:
  • Phone: 505-946-7677
  • Fax: 505-986-1569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1318
License Number StateNM

VIII. Authorized Official

Name: DR. PHYLLIS NADINE GONZALES
Title or Position: OWNER
Credential: DC, BSN-RN
Phone: 505-946-7677