Healthcare Provider Details

I. General information

NPI: 1962681056
Provider Name (Legal Business Name): RIO RANCHO MID-HIGH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 40TH ST NE
RIO RANCHO NM
87144-7708
US

IV. Provider business mailing address

1600 40TH ST NE
RIO RANCHO NM
87144-7708
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-5335
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberI-3395
License Number StateNM

VIII. Authorized Official

Name: MRS. LISA DOBSON
Title or Position: PRINCIPAL
Credential:
Phone: 505-823-1569