Healthcare Provider Details

I. General information

NPI: 1619072915
Provider Name (Legal Business Name): SAN VICENTE HOME HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N ARIZONA ST
SILVER CITY NM
88061-4963
US

IV. Provider business mailing address

PO BOX 2307
SILVER CITY NM
88062-2307
US

V. Phone/Fax

Practice location:
  • Phone: 505-538-0912
  • Fax: 505-538-0917
Mailing address:
  • Phone: 505-538-0912
  • Fax: 505-538-0917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number6549
License Number StateNM

VIII. Authorized Official

Name: MS. MISTY D GONZALES
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 505-538-0912