Healthcare Provider Details

I. General information

NPI: 1215029574
Provider Name (Legal Business Name): EDMUNDO E APODACA LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 10TH AVE NE
RIO RANCHO NM
87144-4135
US

IV. Provider business mailing address

504 10TH AVE NE
RIO RANCHO NM
87144-4135
US

V. Phone/Fax

Practice location:
  • Phone: 505-385-7947
  • Fax:
Mailing address:
  • Phone: 505-385-7947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-05931
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: