Healthcare Provider Details

I. General information

NPI: 1659805042
Provider Name (Legal Business Name): INGRID YOGITA BUTLER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11930 MENAUL BLVD NE SUITE 106A
ALBUQUERQUE NM
87112-2478
US

IV. Provider business mailing address

PO BOX 20246
ALBUQUERQUE NM
87154-0246
US

V. Phone/Fax

Practice location:
  • Phone: 505-414-7620
  • Fax:
Mailing address:
  • Phone: 505-414-7620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number5899
License Number StateNM

VIII. Authorized Official

Name: DR. INGRID YOGITA BUTLER
Title or Position: OWNER/SOLE PROPRIETOR
Credential: LMT
Phone: 505-414-7620