Healthcare Provider Details

I. General information

NPI: 1497436463
Provider Name (Legal Business Name): GARY B. MARES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 CALLE CHAMISAL
ESPANOLA NM
87532-2976
US

IV. Provider business mailing address

1125 10TH ST NW
ALBUQUERQUE NM
87104-2101
US

V. Phone/Fax

Practice location:
  • Phone: 505-372-4511
  • Fax:
Mailing address:
  • Phone: 505-322-0137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number1025
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: