Provider Demographics
NPI:1972654580
Name:SANTA ANA MEDICAL CLINIC
Entity Type:Organization
Organization Name:SANTA ANA MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONORA
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-954-4422
Mailing Address - Street 1:683 HARKLE RD STE B
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4750
Mailing Address - Country:US
Mailing Address - Phone:505-954-4422
Mailing Address - Fax:505-954-4433
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:505-954-4422
Practice Address - Fax:505-954-4433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCS00008623207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM32466Medicaid
NMD43223Medicare ID - Type Unspecified
NM32466Medicaid