Healthcare Provider Details

I. General information

NPI: 1750196275
Provider Name (Legal Business Name): DARREN TYLER SECATERO LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2025
Last Update Date: 02/11/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 MEDICINE HORSE DR.
TOHAJIILEE NM
87114
US

IV. Provider business mailing address

129 MEDICINE HORSE DR
CANONCITO NM
87026
US

V. Phone/Fax

Practice location:
  • Phone: 505-908-2307
  • Fax:
Mailing address:
  • Phone: 505-908-2307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number68008
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: