Healthcare Provider Details

I. General information

NPI: 1649537978
Provider Name (Legal Business Name): ST JOHNS COLLEGE HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 CAMINO CRUZ BLANCA
SANTA FE NM
87505-4599
US

IV. Provider business mailing address

1160 CAMINO CRUZ BLANCA
SANTA FE NM
87505-4599
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-6418
  • Fax:
Mailing address:
  • Phone: 505-984-6418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JAMES K IRUNGU
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 877-614-5227