=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427869569
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN JUAN COLLEGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2025
-----------------------------------------------------
Last Update Date | 01/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4601 COLLEGE BLVD
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87402-4699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-566-4255
-----------------------------------------------------
Fax | 505-566-3770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4601 COLLEGE BLVD
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87402-4699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-566-4255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HEALTH CENTER DIRECTOR
-----------------------------------------------------
Name | CHARISSE BUCHANAN
-----------------------------------------------------
Credential | AG-NP-C
-----------------------------------------------------
Telephone | 505-566-3313
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------