Healthcare Provider Details

I. General information

NPI: 1376294249
Provider Name (Legal Business Name): CHRISTOPHER OLIVAS CPSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 CALLE CHAMISAL
ESPANOLA NM
87532-2976
US

IV. Provider business mailing address

PO BOX 2785
ESPANOLA NM
87532-4785
US

V. Phone/Fax

Practice location:
  • Phone: 575-200-0850
  • Fax:
Mailing address:
  • Phone: 575-200-0850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: