Healthcare Provider Details

I. General information

NPI: 1255752002
Provider Name (Legal Business Name): RENAE GRIEGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RENAE NICOLE GRIEGO COTA/L

II. Dates (important events)

Enumeration Date: 12/20/2013
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 LUNA AVE
LOS LUNAS NM
87031
US

IV. Provider business mailing address

10823 JEWEL CAVE RD SE
ALBUQUERQUE NM
87123-5910
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-9636
  • Fax:
Mailing address:
  • Phone: 505-239-6430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1240
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: