Healthcare Provider Details

I. General information

NPI: 1124315577
Provider Name (Legal Business Name): GRD HEALTH CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 N PASEO DE ONATE
ESPANOLA NM
87532-2618
US

IV. Provider business mailing address

510 N PASEO DE ONATE
ESPANOLA NM
87532-2618
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-3369
  • Fax: 505-753-4006
Mailing address:
  • Phone: 505-753-3369
  • Fax: 505-753-4006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number444
License Number StateNM

VIII. Authorized Official

Name: MRS. JIWAN KHALSA
Title or Position: DOMRX2
Credential: DOM RX2
Phone: 505-753-3369