Healthcare Provider Details

I. General information

NPI: 1346938818
Provider Name (Legal Business Name): ROGELIO CRUZ PULIDO LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1817 WELLSPRING AVE SE STE D
RIO RANCHO NM
87124-4956
US

IV. Provider business mailing address

8900 THOR RD SW
ALBUQUERQUE NM
87121-9324
US

V. Phone/Fax

Practice location:
  • Phone: 505-828-3837
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB20240565
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: