Healthcare Provider Details

I. General information

NPI: 1003448523
Provider Name (Legal Business Name): JUDAH ARCHULETA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 COUNTRY CLUB CIR
LAS CRUCES NM
88001-1553
US

IV. Provider business mailing address

1435 COUNTRY CLUB CIR
LAS CRUCES NM
88001-1553
US

V. Phone/Fax

Practice location:
  • Phone: 575-932-8267
  • Fax:
Mailing address:
  • Phone: 575-932-8267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: