Healthcare Provider Details

I. General information

NPI: 1083986871
Provider Name (Legal Business Name): JEANETTE VICE TOLEDO VICE LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 79 BOX 1510
OJO ENCINO NM
87013-9612
US

IV. Provider business mailing address

HC 79 BOX 1508
OJO ENCINO NM
87013-9612
US

V. Phone/Fax

Practice location:
  • Phone: 505-731-1500
  • Fax: 505-731-1502
Mailing address:
  • Phone: 505-731-1505
  • Fax: 505-731-1502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number070481
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: