Facts
- Status
- A
- Credential
- LPCC
- Type
- Individual
- Enumeration date
- 2006-09-07
- Last updated
- 2007-07-09
Specialties
Licenses
- License NM
- 91521
Location
- Practice location
- 09 LLANO VISTA RD, BLACK LAKE DIVISION
- City
- ANGEL FIRE NM
- Postal code
- 87710
- Phone
- 505-377-3193
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
Search this city from the state hub for other records in the public registry.
Removal request
Public data from NPPES and CMS. Not a credentialing determination.