Provider Demographics
NPI:1114920717
Name:SAN MIGUEL CLINIC CORP
Entity Type:Organization
Organization Name:SAN MIGUEL CLINIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:FEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-221-3641
Mailing Address - Street 1:PO BOX 5009
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37024-5009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 LEGION DR STE A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4898
Practice Address - Country:US
Practice Address - Phone:505-454-9499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM47485817Medicaid
NM400521153Medicare PIN