Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2025-04-17
- Last updated
- 2025-04-17
Licenses
- License NV
- 17-0804
Location
- Practice location
- 5113 MCNUTT RD UNIT 906
- City
- SANTA TERESA NM
- Postal code
- 880089595
- Phone
- 915-218-3255
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.