Healthcare Provider Details

I. General information

NPI: 1285881565
Provider Name (Legal Business Name): VIRGINIA MARIE MATHES MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 01/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 ENCINO PL NE BLDG F
ALBUQUERQUE NM
87102-2612
US

IV. Provider business mailing address

1129 QUINCY ST SE
ALBUQUERQUE NM
87108-4521
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-1312
  • Fax:
Mailing address:
  • Phone: 505-925-1866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD 0727
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: