Provider Demographics
NPI:1609885243
Name:SANDIA MOUNTAIN MEDICAL, INC.
Entity type:Organization
Organization Name:SANDIA MOUNTAIN MEDICAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-832-4434
Mailing Address - Street 1:12127B HWY 14 N STE 5
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9499
Mailing Address - Country:US
Mailing Address - Phone:505-286-2396
Mailing Address - Fax:505-286-2398
Practice Address - Street 1:1851 OLD US 66
Practice Address - Street 2:UNIT 1
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-6784
Practice Address - Country:US
Practice Address - Phone:505-286-2396
Practice Address - Fax:505-286-2398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty