Provider Demographics
NPI:1629792247
Name:ENCHANTMENT CONCIERGE FAMILY PRACTICE
Entity Type:Organization
Organization Name:ENCHANTMENT CONCIERGE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP-C OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GURULE
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APRN, NP-C
Authorized Official - Phone:505-681-5287
Mailing Address - Street 1:6016 KILMER AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1410
Mailing Address - Country:US
Mailing Address - Phone:505-681-5287
Mailing Address - Fax:
Practice Address - Street 1:6016 KILMER AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1410
Practice Address - Country:US
Practice Address - Phone:505-681-5287
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
1467127845OtherNPI