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General NPI Number Information
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NPI Number | 1477720035
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Entity Type | Organization
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Legal Business Name | SAGE FAMILY MEDICINE
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Dates
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Enumeration Date | 05/13/2008
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Last Update Date | 05/13/2008
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Provider Practice Location Address
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Address Line | 3751 N BUTLER AVE
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City | FARMINGTON
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State | NM
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Zip | 87401-6435
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Country | US
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Telephone | 505-566-1915
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Fax | 505-566-1918
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Provider Business Mailing Address
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Address Line | 3451 N BUTLER AVE
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City | FARMINGTON
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State | NM
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Zip | 87401-2357
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Country | US
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Telephone | 505-566-1915
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Fax | 505-566-1918
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Authorized Official
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Title or Position | OFFICE/CLINICAL MGR
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Name | SUE M BRATCHER
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Credential | RN
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Telephone | 505-566-1915
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 98-109
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License Number State | NM
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