Healthcare Provider Details

I. General information

NPI: 1558665893
Provider Name (Legal Business Name): ANITA M. ROYBAL FAMILY AND PREVENTIVE HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2010
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 JACKIE RD SE STE 400 SUITE 201
RIO RANCHO NM
87124-1045
US

IV. Provider business mailing address

1316 JACKIE RD SE STE 400 SUITE 201
RIO RANCHO NM
87124-1045
US

V. Phone/Fax

Practice location:
  • Phone: 505-234-1612
  • Fax: 505-234-1618
Mailing address:
  • Phone: 505-234-1612
  • Fax: 505-234-1618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number84110
License Number StateNM

VIII. Authorized Official

Name: ANITA M ROYBAL
Title or Position: M.D.
Credential:
Phone: 505-234-1612