Healthcare Provider Details

I. General information

NPI: 1740518851
Provider Name (Legal Business Name): MADDOG MECHANICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 12/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2125 LOS LENTES RD NE
LOS LUNAS NM
87031-6532
US

IV. Provider business mailing address

2125 LOS LENTES RD NE
LOS LUNAS NM
87031-6532
US

V. Phone/Fax

Practice location:
  • Phone: 505-550-0335
  • Fax:
Mailing address:
  • Phone: 505-550-0335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number356742
License Number StateNM

VIII. Authorized Official

Name: MR. EDWARD R FINLEY
Title or Position: PARTNER
Credential:
Phone: 505-550-0335