Healthcare Provider Details

I. General information

NPI: 1023397916
Provider Name (Legal Business Name): MS. ERICA MICHELLE GRIEGO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 CHILDERS DR NE
ALBUQUERQUE NM
87112-5107
US

IV. Provider business mailing address

1204 CHILDERS DR NE
ALBUQUERQUE NM
87112-5107
US

V. Phone/Fax

Practice location:
  • Phone: 505-980-2440
  • Fax:
Mailing address:
  • Phone: 505-980-2440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberT-0142151
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: