Healthcare Provider Details

I. General information

NPI: 1174678817
Provider Name (Legal Business Name): KATHLEEN MARTINA MADRID L. M.T. #505
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1167A HIGHWAY 554
EL RITO NM
87530-0805
US

IV. Provider business mailing address

PO BOX 414 HCR 77 BOX F9
OJO CALIENTE NM
87549-0414
US

V. Phone/Fax

Practice location:
  • Phone: 505-581-0033
  • Fax: 505-581-0034
Mailing address:
  • Phone: 505-747-9798
  • Fax: 505-747-9798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberL.M.T. #505
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: