Healthcare Provider Details

I. General information

NPI: 1649288713
Provider Name (Legal Business Name): RIO ABAJO FAMILY PRACTICE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 SANDOVAL RD SW
LOS LUNAS NM
87031-7320
US

IV. Provider business mailing address

PO BOX 3469
LOS LUNAS NM
87031-3469
US

V. Phone/Fax

Practice location:
  • Phone: 505-565-4355
  • Fax: 505-565-4360
Mailing address:
  • Phone: 505-565-4355
  • Fax: 505-565-4360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BOBBI HARRIS
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 505-507-2509