Healthcare Provider Details

I. General information

NPI: 1114228954
Provider Name (Legal Business Name): DOLORES M CISNEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2010
Last Update Date: 11/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 VENADITO TRL
ANTHONY NM
88021-9050
US

IV. Provider business mailing address

2200 VENADITO TRL
ANTHONY NM
88021-9050
US

V. Phone/Fax

Practice location:
  • Phone: 915-820-9275
  • Fax:
Mailing address:
  • Phone: 915-820-9275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: