Healthcare Provider Details

I. General information

NPI: 1255785218
Provider Name (Legal Business Name): HAR DEV KHALSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 SHADY LN
ESPANOLA NM
87532-9030
US

IV. Provider business mailing address

21 OLD DUMP RD.
ESPANOLA NM
87532
US

V. Phone/Fax

Practice location:
  • Phone: 505-593-3538
  • Fax:
Mailing address:
  • Phone: 505-593-3538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: