Healthcare Provider Details

I. General information

NPI: 1912915307
Provider Name (Legal Business Name): RAYMOND E BAMBERG BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 N TELSHOR BLVD SUITE A
LAS CRUCES NM
88011-8244
US

IV. Provider business mailing address

920 N TELSHOR BLVD SUITE A
LAS CRUCES NM
88011-8244
US

V. Phone/Fax

Practice location:
  • Phone: 505-523-8816
  • Fax: 505-522-0026
Mailing address:
  • Phone: 505-523-8816
  • Fax: 505-522-0026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number290
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: