Healthcare Provider Details

I. General information

NPI: 1063334712
Provider Name (Legal Business Name): CARLOS LATOMA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 EAGLE COURT
SANTO DOMINGO PUEBLO NM
87052
US

IV. Provider business mailing address

29 RAINWATER RD
ALGODONES NM
87001-5031
US

V. Phone/Fax

Practice location:
  • Phone: 505-709-7277
  • Fax:
Mailing address:
  • Phone: 505-709-7277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberG-2096
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: