Healthcare Provider Details

I. General information

NPI: 1962992065
Provider Name (Legal Business Name): POLIBIA A HERNANDEZ RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 FRED DAUGHERTY AVE
CLOVIS NM
88101-8606
US

IV. Provider business mailing address

2100 FRED DAUGHERTY AVE APT F
CLOVIS NM
88101-8606
US

V. Phone/Fax

Practice location:
  • Phone: 862-232-3620
  • Fax:
Mailing address:
  • Phone: 862-232-3620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number515953663
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: