Healthcare Provider Details

I. General information

NPI: 1831723899
Provider Name (Legal Business Name): RANDALL ZUNI CPSW,BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2020
Last Update Date: 02/28/2020
Certification Date: 02/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 VANDENBOSCH PKWY
GALLUP NM
87301-5508
US

IV. Provider business mailing address

650 VANDENBOSCH PKWY
GALLUP NM
87301-5508
US

V. Phone/Fax

Practice location:
  • Phone: 505-726-6919
  • Fax: 505-726-6937
Mailing address:
  • Phone: 505-726-6919
  • Fax: 505-726-6937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number1050
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: