Healthcare Provider Details

I. General information

NPI: 1720416498
Provider Name (Legal Business Name): ELLIOT KRAMER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2013
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 GUTIERREZ RD
CORRALES NM
87048-8467
US

IV. Provider business mailing address

PO BOX 3197
CORRALES NM
87048-3197
US

V. Phone/Fax

Practice location:
  • Phone: 505-301-3629
  • Fax:
Mailing address:
  • Phone: 505-301-3629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number4550
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: