MEDICARE: SAN MIGUEL CLINIC CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114920717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN MIGUEL CLINIC CORP

Provider Business Mailing Address
First Line	:	PO BOX 5009
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37024-5009
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	108 LEGION DR STE A
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4898
Country	:	US
Telephone Number	:	505-454-9499
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR REVENUE CYCLE
Name	:	LAURA J FEY
Credential	:
Telephone Number	:	615-221-3641

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	10/17/2023

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Directions to “SAN MIGUEL CLINIC CORP ” Practice Location

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