Healthcare Provider Details

I. General information

NPI: 1235789157
Provider Name (Legal Business Name): PATRICK O OBERMULLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2019
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 MOUNTAIN TRAIL LOOP NE
RIO RANCHO NM
87144-7012
US

IV. Provider business mailing address

PO BOX 44971
RIO RANCHO NM
87174-4971
US

V. Phone/Fax

Practice location:
  • Phone: 575-415-8575
  • Fax:
Mailing address:
  • Phone: 575-415-8575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAD0200771
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: