Healthcare Provider Details

I. General information

NPI: 1356274146
Provider Name (Legal Business Name): LUIS ACOSTA QUINTANA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 ESMERALDA DR NW
ALBUQUERQUE NM
87114-6344
US

IV. Provider business mailing address

10800 ESMERALDA DR NW
ALBUQUERQUE NM
87114-6344
US

V. Phone/Fax

Practice location:
  • Phone: 505-507-1205
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number75520
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: