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General NPI Number Information
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NPI Number | 1700240991
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Entity Type | Organization
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Legal Business Name | DENOVO CLINICAL SPECIALISTS, P.C.
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Dates
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Enumeration Date | 04/13/2016
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Last Update Date | 04/13/2016
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Provider Practice Location Address
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Address Line | 1245 COUNTRY CLUB RD STE 200
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City | SANTA TERESA
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State | NM
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Zip | 88008-9743
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Country | US
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Telephone | 575-332-4633
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Fax | 575-332-4633
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Provider Business Mailing Address
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Address Line | 1245 COUNTRY CLUB RD STE 200
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City | SANTA TERESA
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State | NM
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Zip | 88008-9743
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Country | US
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Telephone | 575-332-4633
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Fax | 575-332-4633
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | MRS. LORENA CARRILLO HENDERSON
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Credential | APRN,MSN,FNP-C
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Telephone | 956-739-1796
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | CNP-02601
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License Number State | NM
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