Healthcare Provider Details

I. General information

NPI: 1699905927
Provider Name (Legal Business Name): EDGEWOOD PEDIATRIC CLINIC L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 05/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 EUNICE CT BLDG B
EDGEWOOD NM
87015-9108
US

IV. Provider business mailing address

PO BOX 1320
EDGEWOOD NM
87015-1320
US

V. Phone/Fax

Practice location:
  • Phone: 505-281-4620
  • Fax: 505-281-0397
Mailing address:
  • Phone: 505-281-4620
  • Fax: 505-281-0397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2003-0092
License Number StateNM

VIII. Authorized Official

Name: DR. SHARON DIANE GARNAND
Title or Position: OWNER
Credential: MD
Phone: 505-281-4620