Healthcare Provider Details

I. General information

NPI: 1023362274
Provider Name (Legal Business Name): TERESA MARQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2012
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E ROOSEVELT AVE SUITE 415
GRANTS NM
87020-2220
US

IV. Provider business mailing address

PO BOX 28220
SANTA FE NM
87592-8220
US

V. Phone/Fax

Practice location:
  • Phone: 505-876-1890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: