Healthcare Provider Details

I. General information

NPI: 1063094217
Provider Name (Legal Business Name): CATHERINE HELENE MIX CCSS WORKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2021
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1424 DEBORAH RD SE STE 205
RIO RANCHO NM
87124-6619
US

IV. Provider business mailing address

1424 DEBORAH RD SE STE 205
RIO RANCHO NM
87124-6619
US

V. Phone/Fax

Practice location:
  • Phone: 505-636-6100
  • Fax:
Mailing address:
  • Phone: 505-750-4855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: