Healthcare Provider Details

I. General information

NPI: 1689706590
Provider Name (Legal Business Name): DANIEL CORDOVA OTRL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 BLUEBIRD RD.
PLACITAS NM
87043-8835
US

IV. Provider business mailing address

20 BLUEBIRD RD.
PLACITAS NM
87043-8835
US

V. Phone/Fax

Practice location:
  • Phone: 505-980-0027
  • Fax: 505-867-1392
Mailing address:
  • Phone: 505-980-0027
  • Fax: 505-867-1392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1785
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: