Provider Demographics
NPI:1568998029
Name:SAN JUAN HEALTH AND WELLNESS CENTER
Entity Type:Organization
Organization Name:SAN JUAN HEALTH AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-327-0002
Mailing Address - Street 1:4801 N BUTLER AVE
Mailing Address - Street 2:STE 1101
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-1013
Mailing Address - Country:US
Mailing Address - Phone:505-327-0002
Mailing Address - Fax:505-325-9443
Practice Address - Street 1:4801 N BUTLER AVE
Practice Address - Street 2:STE 1101
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-1013
Practice Address - Country:US
Practice Address - Phone:505-327-0002
Practice Address - Fax:505-325-9443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM86337556Medicaid
NM2782OtherLAST FOUR OF TIN
NM2782OtherLAST FOUR OF TIN