Healthcare Provider Details

I. General information

NPI: 1629810486
Provider Name (Legal Business Name): 505 DIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1103
US

IV. Provider business mailing address

4225 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1103
US

V. Phone/Fax

Practice location:
  • Phone: 505-361-1931
  • Fax: 505-521-5147
Mailing address:
  • Phone: 505-548-8035
  • Fax: 505-581-3291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. REBEKAH JAN HUTCHINS KHAN
Title or Position: CEO/PROVIDER
Credential:
Phone: 470-728-9352