Healthcare Provider Details

I. General information

NPI: 1912600727
Provider Name (Legal Business Name): MRS. KRYSTAL GRIEGO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7007 JEFFERSON ST NE
ALBUQUERQUE NM
87109-4450
US

IV. Provider business mailing address

1529 PEPPOLI LOOP SE
RIO RANCHO NM
87124-8775
US

V. Phone/Fax

Practice location:
  • Phone: 505-303-0372
  • Fax:
Mailing address:
  • Phone: 505-303-0372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License Number163456
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number163456
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: