Healthcare Provider Details

I. General information

NPI: 1356306237
Provider Name (Legal Business Name): SUSAN DADE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 N 13TH ST STE 300
ARTESIA NM
88210-1133
US

IV. Provider business mailing address

702 N 13TH ST
ARTESIA NM
88210-1199
US

V. Phone/Fax

Practice location:
  • Phone: 575-736-8233
  • Fax:
Mailing address:
  • Phone: 575-748-3333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number103
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: