MEDICARE: DENOVO CLINICAL SPECIALISTS, P.C.

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	261QP2300X	Primary Care Clinic/Center	CNP-02601	NM

General Provider Information

NPI Number	:	1700240991
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENOVO CLINICAL SPECIALISTS, P.C.

Provider Business Mailing Address
First Line	:	1245 COUNTRY CLUB RD STE 200
Second Line	:
City	:	SANTA TERESA
State	:	NM
Zip	:	88008-9743
Country	:	US
Telephone Number	:	575-332-4633
Fax Number	:	575-332-4633

Provider Business Practice Location Address
First Line	:	1245 COUNTRY CLUB RD STE 200
Second Line	:
City	:	SANTA TERESA
State	:	NM
Zip	:	88008-9743
Country	:	US
Telephone Number	:	575-332-4633
Fax Number	:	575-332-4633

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	MRS. LORENA CARRILLO HENDERSON
Credential	:	APRN,MSN,FNP-C
Telephone Number	:	956-739-1796

Provider Enumeration Date	:	04/13/2016
Last Update Date	:	04/13/2016

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