Healthcare Provider Details

I. General information

NPI: 1639505712
Provider Name (Legal Business Name): RIO GRANDE GERIATRICS AND FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8328 CASCADE PARK AVE NW
ALBUQUERQUE NM
87120-6523
US

IV. Provider business mailing address

8328 CASCADE PARK AVE NW
ALBUQUERQUE NM
87120-6523
US

V. Phone/Fax

Practice location:
  • Phone: 505-220-3873
  • Fax: 505-792-5222
Mailing address:
  • Phone: 505-220-3873
  • Fax: 505-792-5222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: MIKE A WALLACE
Title or Position: CEO MEDICAL DIRECTOR
Credential: CNP
Phone: 505-220-3873