Provider Demographics
NPI:1558395475
Name:SANDIA PSYCHIATRIC SERVICES PC
Entity Type:Organization
Organization Name:SANDIA PSYCHIATRIC SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARKE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRUNTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:505-345-4286
Mailing Address - Street 1:2828 12TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-1122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2828 12TH ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1122
Practice Address - Country:US
Practice Address - Phone:505-345-4286
Practice Address - Fax:505-341-0318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA1160012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty