Healthcare Provider Details

I. General information

NPI: 1184553000
Provider Name (Legal Business Name): EDWARD ELBERT DANIELS JR. CCSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ELBERT DANIELS CCSS

II. Dates (important events)

Enumeration Date: 05/16/2026
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 SARA RD SE STE 106
RIO RANCHO NM
87124-1524
US

IV. Provider business mailing address

1814 BUCKSKIN LOOP NE
RIO RANCHO NM
87144-1451
US

V. Phone/Fax

Practice location:
  • Phone: 505-537-2543
  • Fax:
Mailing address:
  • Phone: 505-537-2543
  • 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: