Provider Demographics
NPI:1568577914
Name:SAN JUAN CENTER FOR INDEPENDENCE
Entity Type:Organization
Organization Name:SAN JUAN CENTER FOR INDEPENDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:CARVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-566-5827
Mailing Address - Street 1:1204 SAN JUAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2724
Mailing Address - Country:US
Mailing Address - Phone:505-566-5827
Mailing Address - Fax:505-566-5842
Practice Address - Street 1:1204 SAN JUAN BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2724
Practice Address - Country:US
Practice Address - Phone:505-566-5827
Practice Address - Fax:505-566-5842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ9242Medicaid