Healthcare Provider Details

I. General information

NPI: 1922299130
Provider Name (Legal Business Name): MICHAEL MARTIN GRIJALVA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 06/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8400 MENAUL BLVD NE SUTIE F.
ALBUQUERQUE NM
87112-2260
US

IV. Provider business mailing address

8400 MENAUL BLVD NE SUTIE F.
ALBUQUERQUE NM
87112-2260
US

V. Phone/Fax

Practice location:
  • Phone: 505-299-7777
  • Fax: 505-299-7777
Mailing address:
  • Phone: 505-299-7777
  • Fax: 505-299-7777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number0803
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: