Healthcare Provider Details

I. General information

NPI: 1124700562
Provider Name (Legal Business Name): VICTORIA MAE GARCIA CDP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2023
Last Update Date: 08/04/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 BIG CHEIF RD
ILFELD NM
87538
US

IV. Provider business mailing address

HC 73 BOX 549
SAN JOSE NM
87565-9714
US

V. Phone/Fax

Practice location:
  • Phone: 505-469-7773
  • Fax: 505-657-7733
Mailing address:
  • Phone: 505-469-7773
  • Fax: 505-657-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2278H0200X
TaxonomyHome Health Certified Respiratory Therapist
License Number6888283
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: