Provider Demographics
NPI:1962849950
Name:ENCHANTMENT HEALTHCARE,LLC
Entity Type:Organization
Organization Name:ENCHANTMENT HEALTHCARE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:SISNEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-615-8336
Mailing Address - Street 1:106 MAIN ST NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-7559
Mailing Address - Country:US
Mailing Address - Phone:505-565-0070
Mailing Address - Fax:505-565-0978
Practice Address - Street 1:106 MAIN ST NE
Practice Address - Street 2:SUITE A
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7559
Practice Address - Country:US
Practice Address - Phone:505-565-0070
Practice Address - Fax:505-565-0978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM84-288207Q00000X
NMPA2005-0037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty