Healthcare Provider Details

I. General information

NPI: 1740556893
Provider Name (Legal Business Name): KIDSBRIDGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 BLEDSOE RD NW
LOS RANCHOS NM
87107-6219
US

IV. Provider business mailing address

1104 SALAMANCA ST NW
LOS RANCHOS NM
87107-5626
US

V. Phone/Fax

Practice location:
  • Phone: 505-908-0717
  • Fax: 505-344-5553
Mailing address:
  • Phone: 505-908-0717
  • Fax: 505-344-5553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number2414
License Number StateNM

VIII. Authorized Official

Name: MRS. KRISTEN S WIESE
Title or Position: OWNER / OPERATOR
Credential: MA OTR/L
Phone: 505-908-0717