Healthcare Provider Details

I. General information

NPI: 1912081969
Provider Name (Legal Business Name): OLIVIA GRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 LUNA ST SE
LOS LUNAS NM
87031-9277
US

IV. Provider business mailing address

4 GAUCHO RD
BELEN NM
87002-8556
US

V. Phone/Fax

Practice location:
  • Phone: 505-565-1619
  • Fax: 505-565-1620
Mailing address:
  • Phone: 505-565-1619
  • Fax: 505-565-1620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: