Provider Demographics
NPI:1205010881
Name:AGNES MARTINEZ FAMILY HEALTH CLINIC
Entity Type:Organization
Organization Name:AGNES MARTINEZ FAMILY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNKER
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:505-387-5503
Mailing Address - Street 1:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:NM
Mailing Address - Zip Code:87732-0185
Mailing Address - Country:US
Mailing Address - Phone:505-387-5503
Mailing Address - Fax:505-387-5502
Practice Address - Street 1:STATE HIGHWAY 518 MILE MARKER 29
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:NM
Practice Address - Zip Code:87732-0185
Practice Address - Country:US
Practice Address - Phone:505-387-5503
Practice Address - Fax:505-387-5502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM363LF0000X261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service