Healthcare Provider Details

I. General information

NPI: 1285523258
Provider Name (Legal Business Name): EKENE OBINNA MADU B.A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2025
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 MOUNTAIN HAWK LOOP NE
RIO RANCHO NM
87144-7511
US

IV. Provider business mailing address

6565 MOUNTAIN HAWK LOOP NE
RIO RANCHO NM
87144-7511
US

V. Phone/Fax

Practice location:
  • Phone: 505-416-1951
  • Fax:
Mailing address:
  • Phone: 505-416-1951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number1618646749
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: