Healthcare Provider Details

I. General information

NPI: 1104803675
Provider Name (Legal Business Name): COTTONTREE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 03/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 CENTRAL PARK SQ SUITE 105
LOS ALAMOS NM
87544-4001
US

IV. Provider business mailing address

190 CENTRAL PARK SQ SUITE 105
LOS ALAMOS NM
87544-4001
US

V. Phone/Fax

Practice location:
  • Phone: 505-662-1419
  • Fax: 505-672-1739
Mailing address:
  • Phone: 505-662-1419
  • Fax: 505-672-1739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number200110082
License Number StateNM

VIII. Authorized Official

Name: DONNA MARIE GIAQUINTO
Title or Position: DIRECTOR
Credential: LPCC
Phone: 505-662-1419