Healthcare Provider Details

I. General information

NPI: 1760735591
Provider Name (Legal Business Name): VALENCIA VALLEY HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ISLETA BLVD SW
ALBUQUERQUE NM
87105-3896
US

IV. Provider business mailing address

PO BOX 3439
LOS LUNAS NM
87031-3439
US

V. Phone/Fax

Practice location:
  • Phone: 505-200-2647
  • Fax:
Mailing address:
  • Phone: 505-200-2647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR37352
License Number StateNM

VIII. Authorized Official

Name: JOSE ROLANDO FLORES
Title or Position: PARTNER/CFNP
Credential:
Phone: 505-200-2647