Provider Demographics
NPI:1639121692
Name:DOCTORS OF SANTA TERESA PC
Entity Type:Organization
Organization Name:DOCTORS OF SANTA TERESA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-589-1144
Mailing Address - Street 1:PO BOX 1590
Mailing Address - Street 2:
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-9648
Mailing Address - Country:US
Mailing Address - Phone:575-589-1144
Mailing Address - Fax:575-589-2008
Practice Address - Street 1:5290 MCNUTT ROAD
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9648
Practice Address - Country:US
Practice Address - Phone:575-589-1144
Practice Address - Fax:575-589-2008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCL00010400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM7908OtherBCBS
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