Healthcare Provider Details

I. General information

NPI: 1487754735
Provider Name (Legal Business Name): HIGH DESERT NEUROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 12/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4131 BARBARA LOOP SE SUITE 1-A
RIO RANCHO NM
87124-1362
US

IV. Provider business mailing address

PO BOX 44430
RIO RANCHO NM
87174-4430
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-8915
  • Fax: 505-994-3028
Mailing address:
  • Phone: 505-892-8915
  • Fax: 505-994-3028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JERRY K WILLIAMS JR.
Title or Position: PRINCIPAL
Credential: MD
Phone: 505-892-8915