Healthcare Provider Details

I. General information

NPI: 1134192008
Provider Name (Legal Business Name): REBECCA H. KOONTZ CPED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5011 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1350
US

IV. Provider business mailing address

6712 CHRISTY AVE NE
ALBUQUERQUE NM
87109-4000
US

V. Phone/Fax

Practice location:
  • Phone: 505-872-3668
  • Fax: 505-888-7041
Mailing address:
  • Phone: 505-610-9250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number10852
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: