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General NPI Number Information
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NPI Number | 1568998029
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Entity Type | Organization
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Legal Business Name | SAN JUAN HEALTH AND WELLNESS CENTER
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Dates
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Enumeration Date | 05/03/2017
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Last Update Date | 12/29/2023
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Provider Practice Location Address
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Address Line | 4801 N BUTLER AVE STE 1101
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City | FARMINGTON
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State | NM
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Zip | 87401-1013
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Country | US
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Telephone | 505-327-0002
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Fax | 505-325-9443
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Provider Business Mailing Address
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Address Line | 4801 N BUTLER AVE STE 1101
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City | FARMINGTON
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State | NM
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Zip | 87401-1013
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Country | US
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Telephone | 505-327-0002
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Fax | 505-325-9443
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Authorized Official
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Title or Position | OFFICE ADMINISTRATOR
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Name | MISTY DAWN DIAZ
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Credential |
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Telephone | 505-327-0002
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #3
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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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Taxonomy #4
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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