Healthcare Provider Details

I. General information

NPI: 1811367238
Provider Name (Legal Business Name): MICHELE BOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2015
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date: 07/20/2021
Reactivation Date: 08/03/2021

III. Provider practice location address

1217 1ST ST NW
ALBUQUERQUE NM
87102-1529
US

IV. Provider business mailing address

PO BOX 25445
ALBUQUERQUE NM
87125-0445
US

V. Phone/Fax

Practice location:
  • Phone: 505-766-5197
  • Fax:
Mailing address:
  • Phone: 505-766-5197
  • 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: