Provider Demographics
NPI:1962536326
Name:SANGRE DE CRISTO FAMILY PRACTICE ASSOC., P.C.
Entity type:Organization
Organization Name:SANGRE DE CRISTO FAMILY PRACTICE ASSOC., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BANKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-275-8646
Mailing Address - Street 1:712 MACON AVE
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-3314
Mailing Address - Country:US
Mailing Address - Phone:719-275-8646
Mailing Address - Fax:888-484-0223
Practice Address - Street 1:712 MACON AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-3314
Practice Address - Country:US
Practice Address - Phone:719-275-8646
Practice Address - Fax:888-484-0223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27050261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04119046Medicaid
CO04119046Medicaid