Healthcare Provider Details

I. General information

NPI: 1780337378
Provider Name (Legal Business Name): ABQ DNA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7328 SANDMARK RD NW
ALBUQUERQUE NM
87114-6420
US

IV. Provider business mailing address

1380 RIO RANCHO DR SE # 262
ALBUQUERQUE NM
87124-1006
US

V. Phone/Fax

Practice location:
  • Phone: 505-410-1924
  • Fax:
Mailing address:
  • Phone: 505-410-1924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DEVANG R BUTANI
Title or Position: CEO
Credential: DO
Phone: 505-410-1924