Healthcare Provider Details

I. General information

NPI: 1710212006
Provider Name (Legal Business Name): PETER COSBY VANLENT LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 10/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JOHN HYSON DR. BLD 4,5,6
CHIMAYO NM
87522-0757
US

IV. Provider business mailing address

PO BOX 757
CHIMAYO NM
87522-0757
US

V. Phone/Fax

Practice location:
  • Phone: 505-351-0900
  • Fax:
Mailing address:
  • Phone: 505-351-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number005938
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: