Healthcare Provider Details

I. General information

NPI: 1801003231
Provider Name (Legal Business Name): PETROGLYPH PATHOLOGY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 10/02/2014
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: 505-924-0210
Mailing address:
  • Phone: 505-924-0209
  • Fax: 505-924-0210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. SANDRA M MUELLER
Title or Position: PATHOLOGIST
Credential: M.D.
Phone: 505-924-0209