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General NPI Number Information
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NPI Number | 1922039171
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Entity Type | Organization
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Legal Business Name | SANTA ROSA MEDICAL CLINIC
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Dates
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Enumeration Date | 07/06/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 533 LAKE DR
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City | SANTA ROSA
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State | NM
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Zip | 88435
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Country | US
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Telephone | 505-472-4311
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Fax | 505-472-4313
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Provider Business Mailing Address
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Address Line | 533 LAKE DR
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City | SANTA ROSA
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State | NM
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Zip | 88435
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Country | US
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Telephone | 505-472-4311
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Fax | 505-472-4313
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Authorized Official
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Title or Position | MEDICAL DOCTOR
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Name | MR. SERGIO EDGARDO ABRIOLA
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Credential | MD
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Telephone | 505-472-4311
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 20020002
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License Number State | NM
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