Healthcare Provider Details

I. General information

NPI: 1659669828
Provider Name (Legal Business Name): MRS. JACQUELINE TENEILLE ROCHE-CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2011
Last Update Date: 07/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 PONDEROSA AVE. NE.
ALBUQUERQUE NM
87110-1216
US

IV. Provider business mailing address

P.O. BOX 35101
ALBUQUERQUE NM
87176
US

V. Phone/Fax

Practice location:
  • Phone: 505-881-8982
  • Fax: 505-872-0392
Mailing address:
  • Phone: 505-881-8982
  • Fax: 505-872-0392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: