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General NPI Number Information
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NPI Number | 1235026261
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Entity Type | Organization
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Legal Business Name | FENTON FAMILY MEDICAL LLC
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Dates
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Enumeration Date | 06/23/2025
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Last Update Date | 06/23/2025
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Provider Practice Location Address
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Address Line | 765 E ROOSEVELT AVE
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City | GRANTS
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State | NM
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Zip | 87020-2113
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Country | US
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Telephone | 505-685-1347
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Fax |
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Provider Business Mailing Address
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Address Line | 824 HOUSTON AVE
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City | GRANTS
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State | NM
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Zip | 87020-3017
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Country | US
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Telephone | 505-315-1162
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Fax | 866-271-1136
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Authorized Official
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Title or Position | OWNER
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Name | DANIEL FENTON
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Credential |
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Telephone | 505-315-1162
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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