Provider Demographics
NPI:1669459947
Name:SANTA TERESA MEDICAL CARE CENTER PC
Entity Type:Organization
Organization Name:SANTA TERESA MEDICAL CARE CENTER PC
Other - Org Name:SANTA TERESA MEDICAL CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:JUAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-842-0504
Mailing Address - Street 1:5055 MCNUTT RD
Mailing Address - Street 2:PO BOX 5
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-9442
Mailing Address - Country:US
Mailing Address - Phone:575-589-5005
Mailing Address - Fax:575-589-1333
Practice Address - Street 1:5055 MCNUTT RD
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9442
Practice Address - Country:US
Practice Address - Phone:575-589-5005
Practice Address - Fax:575-589-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0733024-01Medicaid
NM49189Medicaid
NMCS9566OtherPALMETTO GBA
NM49189Medicaid