1568998029 NPI number — SAN JUAN HEALTH AND WELLNESS CENTER

Table of content: DR. MICHAEL MCQUEEN D.M.D (NPI 1013008671)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568998029 NPI number — SAN JUAN HEALTH AND WELLNESS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN JUAN HEALTH AND WELLNESS CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568998029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4801 N BUTLER AVE
Provider Second Line Business Mailing Address:
STE 1101
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87401-1013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-327-0002
Provider Business Mailing Address Fax Number:
505-325-9443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4801 N BUTLER AVE
Provider Second Line Business Practice Location Address:
STE 1101
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87401-1013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-327-0002
Provider Business Practice Location Address Fax Number:
505-325-9443
Provider Enumeration Date:
05/03/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DIAZ
Authorized Official First Name:
MISTY
Authorized Official Middle Name:
DAWN
Authorized Official Title or Position:
OFFICE ADMINISTRATOR
Authorized Official Telephone Number:
505-327-0002

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 86337556 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2782 . This is a "LAST FOUR OF TIN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".