Healthcare Provider Details

I. General information

NPI: 1225194608
Provider Name (Legal Business Name): RIO GRANDE FOOT CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 S ALAMEDA BLVD
LAS CRUCES NM
88005-2928
US

IV. Provider business mailing address

710 S ALAMEDA BLVD
LAS CRUCES NM
88005-2928
US

V. Phone/Fax

Practice location:
  • Phone: 575-523-8566
  • Fax: 575-525-2065
Mailing address:
  • Phone: 575-523-8566
  • Fax: 575-525-2065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberNM142
License Number StateNM

VIII. Authorized Official

Name: DR. DAVID L DEETZ
Title or Position: OWNER
Credential: D.P.M.
Phone: 575-523-8566