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General NPI Number Information
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NPI Number | 1568577914
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Entity Type | Organization
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Legal Business Name | SAN JUAN CENTER FOR INDEPENDENCE
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Dates
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Enumeration Date | 08/19/2006
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Last Update Date | 10/26/2015
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Provider Practice Location Address
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Address Line | 1204 SAN JUAN BLVD
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City | FARMINGTON
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State | NM
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Zip | 87401-2724
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Country | US
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Telephone | 505-566-5827
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Fax | 505-566-5842
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Provider Business Mailing Address
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Address Line | 1204 SAN JUAN BLVD
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City | FARMINGTON
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State | NM
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Zip | 87401-2724
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Country | US
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Telephone | 505-566-5827
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Fax | 505-566-5842
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | MR. TIMOTHY DEAN CARVER
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Credential |
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Telephone | 505-566-5827
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State | NM
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