Healthcare Provider Details

I. General information

NPI: 1679860175
Provider Name (Legal Business Name): PATIENCE GRASSHOPPER THERAPEUTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 07/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16306 B HWY 84
CHAMA NM
87520
US

IV. Provider business mailing address

PO BOX 301
CHAMA NM
87520-0301
US

V. Phone/Fax

Practice location:
  • Phone: 575-756-8391
  • Fax:
Mailing address:
  • Phone: 575-756-8391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2983
License Number StateNM

VIII. Authorized Official

Name: AMILIA ANNE ELLIOTT
Title or Position: OWNER, PROVIDER
Credential: M.P.T.
Phone: 575-756-8391