Healthcare Provider Details

I. General information

NPI: 1861827644
Provider Name (Legal Business Name): CRAIG KLEIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2013
Last Update Date: 09/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13217 EXECUTIVE RIDGE DR NE
ALBUQUERQUE NM
87112-2140
US

IV. Provider business mailing address

13217 EXECUTIVE RIDGE DR NE
ALBUQUERQUE NM
87112-2140
US

V. Phone/Fax

Practice location:
  • Phone: 505-821-3008
  • Fax:
Mailing address:
  • Phone: 505-821-3008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberLN-0619
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: