Healthcare Provider Details

I. General information

NPI: 1669459947
Provider Name (Legal Business Name): SANTA TERESA MEDICAL CARE CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5055 MCNUTT RD
SANTA TERESA NM
88008-9442
US

IV. Provider business mailing address

5055 MCNUTT RD PO BOX 5
SANTA TERESA NM
88008-9442
US

V. Phone/Fax

Practice location:
  • Phone: 575-589-5005
  • Fax: 575-589-1333
Mailing address:
  • Phone: 575-589-5005
  • Fax: 575-589-1333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. LAURENCE JUAREZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 915-842-0504