Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2007-08-23
- Last updated
- 2014-01-08
Licenses
- License NM
- B-2391
- License NM
- B2391
Location
- Practice location
- 1301 WEST WASHINGTON STREET
- City
- ANTHONY NM
- Postal code
- 88021
- Phone
- 505-882-6200
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.