Healthcare Provider Details

I. General information

NPI: 1699869172
Provider Name (Legal Business Name): EPIDAURUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 GOLD AVENUE SW
ALBUQUERQUE NM
87102
US

IV. Provider business mailing address

PO BOX 3043
TUCSON AZ
85702-3043
US

V. Phone/Fax

Practice location:
  • Phone: 505-246-9300
  • Fax: 505-246-8905
Mailing address:
  • Phone: 520-622-6489
  • Fax: 520-622-6490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. ROD G MULLEN
Title or Position: CEO
Credential:
Phone: 520-749-7178