Healthcare Provider Details

I. General information

NPI: 1396200820
Provider Name (Legal Business Name): JOSEPH ACOSTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2019
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 MANZANO ST NE
ALBUQUERQUE NM
87110-6302
US

IV. Provider business mailing address

501 MINDORO DR SE
RIO RANCHO NM
87124-4316
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-4353
  • Fax:
Mailing address:
  • Phone: 575-202-4830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number171M00000X
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: