Healthcare Provider Details

I. General information

NPI: 1780089151
Provider Name (Legal Business Name): PRECIOUS MEMORIESDOULA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1231 DESERT PAINTBRUSH LOOP NE
RIO RANCHO NM
87144-2608
US

IV. Provider business mailing address

1231 DESERT PAINTBRUSH LOOP NE
RIO RANCHO NM
87144-2608
US

V. Phone/Fax

Practice location:
  • Phone: 505-990-9408
  • Fax:
Mailing address:
  • Phone: 505-990-9408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number4962281
License Number StateNM

VIII. Authorized Official

Name: EVONNIE FOMENTO
Title or Position: OWNER
Credential: SBD
Phone: 505-990-9408