Provider Demographics
NPI:1891975561
Name:SANTA FE PEDIATRIC CARDIOLOGY, PC
Entity Type:Organization
Organization Name:SANTA FE PEDIATRIC CARDIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:C.
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:LA FARGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-982-7661
Mailing Address - Street 1:PO BOX 4760
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-4760
Mailing Address - Country:US
Mailing Address - Phone:505-982-7661
Mailing Address - Fax:505-988-5196
Practice Address - Street 1:683 HARKLE RD STE B
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4750
Practice Address - Country:US
Practice Address - Phone:505-982-7661
Practice Address - Fax:505-988-5196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM12895032080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM35006Medicaid