Healthcare Provider Details

I. General information

NPI: 1033501747
Provider Name (Legal Business Name): PETROGLYPH PATHOLOGY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2015
Last Update Date: 04/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 QUANTUM RD NE
RIO RANCHO NM
87124-4506
US

IV. Provider business mailing address

640 QUANTUM RD NE
RIO RANCHO NM
87124-4506
US

V. Phone/Fax

Practice location:
  • Phone: 505-924-0209
  • Fax:
Mailing address:
  • Phone: 505-924-0209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2002-0204
License Number StateNM

VIII. Authorized Official

Name: DAVID ROWE
Title or Position: LAB MANAGER
Credential:
Phone: 505-924-0209