Healthcare Provider Details

I. General information

NPI: 1639121692
Provider Name (Legal Business Name): DOCTORS OF SANTA TERESA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5290 MCNUTT ROAD
SANTA TERESA NM
88008-9648
US

IV. Provider business mailing address

PO BOX 1590
SANTA TERESA NM
88008-9648
US

V. Phone/Fax

Practice location:
  • Phone: 575-589-1144
  • Fax: 575-589-2008
Mailing address:
  • Phone: 575-589-1144
  • Fax: 575-589-2008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberCL00010400
License Number StateNM

VIII. Authorized Official

Name: JENNIFER LARSEN
Title or Position: ADMINISTRATOR
Credential:
Phone: 575-589-1144