Healthcare Provider Details

I. General information

NPI: 1871126532
Provider Name (Legal Business Name): ISAAC ANDRES SERRANO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2020
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COUNTY RD 102 HOUES 58B
CHIMAYO NM
87522
US

IV. Provider business mailing address

PO BOX 196
SANTA CRUZ NM
87567-0196
US

V. Phone/Fax

Practice location:
  • Phone: 505-930-1589
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: