Healthcare Provider Details

I. General information

NPI: 1326145707
Provider Name (Legal Business Name): POJOAQUE FAMILY PRACTICE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 PETROGLYPH CIR STE. B
SANTA FE NM
87506-1001
US

IV. Provider business mailing address

11 W GUTIERREZ UNIT 3810
SANTA FE NM
87506-0228
US

V. Phone/Fax

Practice location:
  • Phone: 505-455-2842
  • Fax: 505-455-2941
Mailing address:
  • Phone: 505-455-2842
  • Fax: 505-455-2941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number000
License Number StateNM

VIII. Authorized Official

Name: DR. CHARLES JAMES MAESTAS
Title or Position: PRESIDENT/PHYSICIAN
Credential: M.D.
Phone: 505-455-2842