Provider Demographics
NPI:1275836231
Name:SAN JON SCHOOL BASED HEALTH CENTER
Entity Type:Organization
Organization Name:SAN JON SCHOOL BASED HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT OF SCHOOLS
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-576-2467
Mailing Address - Street 1:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:SAN JON
Mailing Address - State:NM
Mailing Address - Zip Code:88434-0005
Mailing Address - Country:US
Mailing Address - Phone:575-576-2273
Mailing Address - Fax:575-576-2273
Practice Address - Street 1:7TH AND ELM STREET
Practice Address - Street 2:
Practice Address - City:SAN JON
Practice Address - State:NM
Practice Address - Zip Code:88434
Practice Address - Country:US
Practice Address - Phone:575-576-2273
Practice Address - Fax:575-576-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1E03Medicaid