Healthcare Provider Details

I. General information

NPI: 1053712190
Provider Name (Legal Business Name): LESLIE J ARCHULETA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2014
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SUN AVE NE STE 650
ALBUQUERQUE NM
87109-4659
US

IV. Provider business mailing address

100 SUN AVE NE STE 650
ALBUQUERQUE NM
87109-4659
US

V. Phone/Fax

Practice location:
  • Phone: 505-980-1743
  • Fax:
Mailing address:
  • Phone: 505-835-6759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberLN-0959
License Number StateNM

VIII. Authorized Official

Name: MRS. LESLIE JADE ARCHULETA
Title or Position: LICENSED NUTRITIONIST
Credential: L.N
Phone: 505-980-1743