Healthcare Provider Details

I. General information

NPI: 1700384286
Provider Name (Legal Business Name): CACTUS FRUIT CLOUD COLLABORATIVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 01/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 LOMAS BLVD NW
ALBUQUERQUE NM
87102-1954
US

IV. Provider business mailing address

920 LOMAS BLVD NW
ALBUQUERQUE NM
87102-1954
US

V. Phone/Fax

Practice location:
  • Phone: 505-554-9327
  • Fax:
Mailing address:
  • Phone: 505-554-9327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10236
License Number StateNM

VIII. Authorized Official

Name: MICHELLE B. SANCHEZ
Title or Position: DIRECTOR
Credential: LCSW
Phone: 505-554-9327