Healthcare Provider Details

I. General information

NPI: 1336228519
Provider Name (Legal Business Name): GEORGIA ROSALIE GRAHAM DR OF CHIROPRACTIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 SAN PEDRO NE SUITE 101
ALBUQUERQUE NM
87110
US

IV. Provider business mailing address

1330 SAN PEDRO NE #101
ALBUQUERQUE NM
87110
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-4697
  • Fax: 505-265-0846
Mailing address:
  • Phone: 505-265-4697
  • Fax: 505-265-0840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number876
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: