Healthcare Provider Details

I. General information

NPI: 1962709956
Provider Name (Legal Business Name): KENNETH DORSEY TISDALE L.C.I.C.I., LMT #548
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2011
Last Update Date: 02/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 EUBANK BLVD NE B1
ALBUQUERQUE NM
87123
US

IV. Provider business mailing address

8400 MENAUL BLVD 8400 MENAUL BLVD. NE. #217
ALBUQUERQUE NM
87112
US

V. Phone/Fax

Practice location:
  • Phone: 505-712-7585
  • Fax:
Mailing address:
  • Phone: 505-712-7585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberLMT # 5488
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: