Healthcare Provider Details

I. General information

NPI: 1245311034
Provider Name (Legal Business Name): TERESA V BALCOMB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 GIBSON SE
ALBUQUERQUE NM
87108
US

IV. Provider business mailing address

PO BOX 27829
ALBUQUERQUE NM
87125
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-7000
  • Fax:
Mailing address:
  • Phone: 505-262-7026
  • Fax: 505-727-9276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number82160
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: