Healthcare Provider Details

I. General information

NPI: 1063513992
Provider Name (Legal Business Name): ROY DALE MCDONNELL B.C.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4117 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1102
US

IV. Provider business mailing address

4117 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1102
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-2927
  • Fax: 505-884-2672
Mailing address:
  • Phone: 505-884-2927
  • Fax: 505-884-2672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: