Healthcare Provider Details

I. General information

NPI: 1750798575
Provider Name (Legal Business Name): DR. REBECCA VAN VLECK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2014
Last Update Date: 07/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12501 MONARCH DR NE
ALBUQUERQUE NM
87123-1542
US

IV. Provider business mailing address

12501 MONARCH DR NE
ALBUQUERQUE NM
87123-1542
US

V. Phone/Fax

Practice location:
  • Phone: 505-259-5022
  • Fax:
Mailing address:
  • Phone: 505-259-5022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberRP00008172
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: