Healthcare Provider Details

I. General information

NPI: 1194060053
Provider Name (Legal Business Name): UNM CDD - MI VIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2012
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 MENAUL BLVD NE
ALBUQUERQUE NM
87107-1851
US

IV. Provider business mailing address

2300 MENAUL BLVD NE
ALBUQUERQUE NM
87107-1851
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-6251
  • Fax:
Mailing address:
  • Phone: 505-272-6251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number91-90
License Number StateNM

VIII. Authorized Official

Name: BRIAN GALLEGOS
Title or Position: ADMINISTRATIVE SUPPORT SUPERVISOR
Credential:
Phone: 505-272-6251