Healthcare Provider Details

I. General information

NPI: 1164181723
Provider Name (Legal Business Name): KRISTEN MICHAELA EADS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2021
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 LOS LENTES RD SE STE 3
LOS LUNAS NM
87031-6018
US

IV. Provider business mailing address

PO BOX 28164
SANTA FE NM
87592-8164
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-3350
  • Fax:
Mailing address:
  • Phone: 505-216-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: