Healthcare Provider Details

I. General information

NPI: 1184351900
Provider Name (Legal Business Name): KENDRA LEE BURGOON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N CALIFORNIA ST
SOCORRO NM
87801-4254
US

IV. Provider business mailing address

1894 CHAPARRAL LOOP
SOCORRO NM
87801-3718
US

V. Phone/Fax

Practice location:
  • Phone: 575-838-8991
  • Fax: 575-838-0423
Mailing address:
  • Phone: 575-838-8991
  • Fax: 575-838-0423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: