Healthcare Provider Details

I. General information

NPI: 1770817652
Provider Name (Legal Business Name): HOWARD RANDALL RUSTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2009
Last Update Date: 09/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 EL CENTRO FAMILIAR BLVD SW # B
ALBUQUERQUE NM
87105-4592
US

IV. Provider business mailing address

2001 B CENTRO FAMILIAR S.W.
ALBUQUERQUE NM
87105
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5786
  • Fax:
Mailing address:
  • Phone: 505-272-5786
  • Fax:

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: