Healthcare Provider Details

I. General information

NPI: 1912690645
Provider Name (Legal Business Name): FULL SPECTRUM GAHT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 RICHMOND DR SE
ALBUQUERQUE NM
87106-2336
US

IV. Provider business mailing address

1001 RICHMOND DR SE
ALBUQUERQUE NM
87106-2336
US

V. Phone/Fax

Practice location:
  • Phone: 505-269-6938
  • Fax: 505-485-0729
Mailing address:
  • Phone: 505-269-6938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN MARY COLLERAN
Title or Position: CEO
Credential: MD
Phone: 505-269-6938