Healthcare Provider Details

I. General information

NPI: 1750913737
Provider Name (Legal Business Name): KARL CHAVEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2020
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5180
US

IV. Provider business mailing address

4049 MERCURY CIR SE
ALBUQUERQUE NM
87116-3022
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 505-990-6955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number58278
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number58278
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: