Provider Demographics
NPI:1073825816
Name:JUAN TABO FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:JUAN TABO FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNETA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-554-1786
Mailing Address - Street 1:3309 JUAN TABO BLVD NE
Mailing Address - Street 2:SUITE C
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-5131
Mailing Address - Country:US
Mailing Address - Phone:505-554-1786
Mailing Address - Fax:505-508-2482
Practice Address - Street 1:3309 JUAN TABO BLVD NE
Practice Address - Street 2:SUITE C
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-5131
Practice Address - Country:US
Practice Address - Phone:505-554-1786
Practice Address - Fax:505-508-2482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2007-0072261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1477790327OtherCURRENT PROVIDER NUMBER