Healthcare Provider Details

I. General information

NPI: 1124809066
Provider Name (Legal Business Name): SANDROCK PODIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2023
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4707 RIO ST
FARMINGTON NM
87402-5323
US

IV. Provider business mailing address

4707 RIO ST
FARMINGTON NM
87402-5323
US

V. Phone/Fax

Practice location:
  • Phone: 505-787-9035
  • Fax:
Mailing address:
  • Phone: 505-787-9003
  • Fax: 505-291-3293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: ERIC HAAG
Title or Position: OWNER/PODIATRIST
Credential: MD
Phone: 505-787-9035