Healthcare Provider Details

I. General information

NPI: 1447632005
Provider Name (Legal Business Name): EILEEN QUEZADA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 S CAMINO DEL PUEBLO STE 2C
BERNALILLO NM
87004-5913
US

IV. Provider business mailing address

314 DON FERNANDO ST
TAOS NM
87571-5953
US

V. Phone/Fax

Practice location:
  • Phone: 505-288-3897
  • Fax:
Mailing address:
  • Phone:
  • 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: