Healthcare Provider Details

I. General information

NPI: 1245063288
Provider Name (Legal Business Name): CHANEL ESCKELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 GOLD AVE SW
ALBUQUERQUE NM
87102-3283
US

IV. Provider business mailing address

400 GOLD AVE SW
ALBUQUERQUE NM
87102-3283
US

V. Phone/Fax

Practice location:
  • Phone: 505-715-4610
  • Fax:
Mailing address:
  • Phone: 505-715-4610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: