Healthcare Provider Details

I. General information

NPI: 1891317426
Provider Name (Legal Business Name): TASKER, HATCH, ROWAN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 07/06/2020
Certification Date: 07/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 EAGLE RANCH RD NW
ALBUQUERQUE NM
87114-6440
US

IV. Provider business mailing address

9201 EAGLE RANCH RD NW
ALBUQUERQUE NM
87114-6440
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-9010
  • Fax: 505-899-4804
Mailing address:
  • Phone: 505-892-9010
  • Fax: 505-899-4804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: EBONIE GONZALES
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 505-850-3769