Healthcare Provider Details

I. General information

NPI: 1699060202
Provider Name (Legal Business Name): JUAN TABO FOOT HEALTH CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 06/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 JUAN TABO BLVD NE SUITE D
ALBUQUERQUE NM
87112-3366
US

IV. Provider business mailing address

1925 JUAN TABO BLVD NE SUITE D
ALBUQUERQUE NM
87112-3366
US

V. Phone/Fax

Practice location:
  • Phone: 505-293-6290
  • Fax: 505-292-3014
Mailing address:
  • Phone: 505-293-6290
  • Fax: 505-292-3014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number145
License Number StateNM

VIII. Authorized Official

Name: DR. RICHARD A WEINSTEIN
Title or Position: PODIATRIST
Credential: DPM
Phone: 505-293-6290