Healthcare Provider Details

I. General information

NPI: 1972008126
Provider Name (Legal Business Name): THEODORE L.A ASHFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 DOMINGO RD NE
ALBUQUERQUE NM
87108-1610
US

IV. Provider business mailing address

5601 DOMINGO RD NE
ALBUQUERQUE NM
87108-1610
US

V. Phone/Fax

Practice location:
  • Phone: 505-998-0450
  • Fax: 505-268-9967
Mailing address:
  • Phone: 505-998-0450
  • Fax: 505-268-9967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: