Healthcare Provider Details

I. General information

NPI: 1194098038
Provider Name (Legal Business Name): KENNETH LUJAN BCHIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 06/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4516 CAPRI COURT NW
ALBUQUERQUE NM
87114
US

IV. Provider business mailing address

4516 CAPRI COURT NW
ALBUQUERQUE NM
87114
US

V. Phone/Fax

Practice location:
  • Phone: 505-792-3539
  • Fax: 505-200-3744
Mailing address:
  • Phone: 505-792-3539
  • Fax: 505-200-3744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number0746
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: