MEDICARE: SAN JUAN CENTER FOR INDEPENDENCE

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	251E00000X	Home Health Agency		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	:	1568577914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN JUAN CENTER FOR INDEPENDENCE

Provider Business Mailing Address
First Line	:	1204 SAN JUAN BLVD
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87401-2724
Country	:	US
Telephone Number	:	505-566-5827
Fax Number	:	505-566-5842

Provider Business Practice Location Address
First Line	:	1204 SAN JUAN BLVD
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87401-2724
Country	:	US
Telephone Number	:	505-566-5827
Fax Number	:	505-566-5842

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MR. TIMOTHY DEAN CARVER
Credential	:
Telephone Number	:	505-566-5827

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	10/26/2015

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Directions to “SAN JUAN CENTER FOR INDEPENDENCE ” Practice Location

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