Healthcare Provider Details

I. General information

NPI: 1124790357
Provider Name (Legal Business Name): RIO GRANDE FNA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2469 CORRALES RD BLDG A, STE B
CORRALES NM
87048
US

IV. Provider business mailing address

1278 CAMINO HERMOSA
CORRALES NM
87048-8653
US

V. Phone/Fax

Practice location:
  • Phone: 505-271-2416
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID ROWE
Title or Position: MANAGER
Credential:
Phone: 505-962-0577