Provider Demographics
NPI:1568475747
Name:BUENVIAJE, JEROME DE CASTRO (DC)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:DE CASTRO
Last Name:BUENVIAJE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 RODEO LN
Mailing Address - Street 2:SUITE D-2
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-6400
Mailing Address - Country:US
Mailing Address - Phone:505-984-0821
Mailing Address - Fax:505-984-0168
Practice Address - Street 1:3600 RODEO LN
Practice Address - Street 2:SUITE D-2
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-6400
Practice Address - Country:US
Practice Address - Phone:505-984-0821
Practice Address - Fax:505-984-0168
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1545111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM019A24OtherBLUE CROSS BLUE SHIELD
NMU90721Medicare UPIN
NM348329602Medicare ID - Type Unspecified