Healthcare Provider Details

I. General information

NPI: 1255400040
Provider Name (Legal Business Name): SANTA FE FAMILY AND FUNCTIONAL MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BOTULPH LANE
SANTA FE NM
87505
US

IV. Provider business mailing address

401 BOTULPH LANE
SANTA FE NM
87505
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-8387
  • Fax: 505-820-2733
Mailing address:
  • Phone: 505-983-8387
  • Fax: 505-820-2733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BRUCE E GOLLUB
Title or Position: PRESIDENT
Credential: MD
Phone: 505-983-8387