MEDICARE: SAN JON SCHOOL BASED HEALTH CENTER

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	261QF0400X	Federally Qualified Health Center (FQHC)		NM

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	:	1275836231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN JON SCHOOL BASED HEALTH CENTER

Provider Business Mailing Address
First Line	:	PO BOX 5
Second Line	:
City	:	SAN JON
State	:	NM
Zip	:	88434-0005
Country	:	US
Telephone Number	:	575-576-2273
Fax Number	:	575-576-2273

Provider Business Practice Location Address
First Line	:	7TH AND ELM STREET
Second Line	:
City	:	SAN JON
State	:	NM
Zip	:	88434
Country	:	US
Telephone Number	:	575-576-2273
Fax Number	:	575-576-2273

Authorized Official
Title or Position	:	SUPERINTENDENT OF SCHOOLS
Name	:	MR. GARY SALAZAR
Credential	:
Telephone Number	:	575-576-2467

Provider Enumeration Date	:	12/14/2010
Last Update Date	:	12/14/2010

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