Healthcare Provider Details

I. General information

NPI: 1316940216
Provider Name (Legal Business Name): PROFESSIONAL HOME HEALTH CARE DE SANTA FE Y LOS ALAMOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CALLE MEDICO
SANTA FE NM
87505-4724
US

IV. Provider business mailing address

10 CALLE MEDICO
SANTA FE NM
87505-4724
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-8581
  • Fax: 505-982-0788
Mailing address:
  • Phone: 505-982-8581
  • Fax: 505-982-0788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number6603
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number6012 A1
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number3068
License Number StateNM

VIII. Authorized Official

Name: MR. BRIAN CONWAY
Title or Position: DIRECTOR OF OPERATIONS
Credential: R.N.
Phone: 505-982-8581