Healthcare Provider Details

I. General information

NPI: 1295830461
Provider Name (Legal Business Name): MICHAEL J ROURKE LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3751 DEL REY BLVD
LAS CRUCES NM
88012-7710
US

IV. Provider business mailing address

PO BOX 16667
LAS CRUCES NM
88004-6667
US

V. Phone/Fax

Practice location:
  • Phone: 505-644-8846
  • Fax: 505-522-5717
Mailing address:
  • Phone: 505-644-8846
  • Fax: 505-522-5717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI-3206
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: