Healthcare Provider Details

I. General information

NPI: 1336020593
Provider Name (Legal Business Name): JAIDYN SKYE BUSTOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2025
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 PALMILLA RD NW
LOS LUNAS NM
87031-4864
US

IV. Provider business mailing address

906 ENTRADA DR SW
LOS LUNAS NM
87031-8656
US

V. Phone/Fax

Practice location:
  • Phone: 505-856-6880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: