Healthcare Provider Details

I. General information

NPI: 1699285155
Provider Name (Legal Business Name): JACOB BRALDEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2017
Last Update Date: 10/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 DUCALE DR SE
RIO RANCHO NM
87124-8772
US

IV. Provider business mailing address

1401 DUCALE DR SE
RIO RANCHO NM
87124-8772
US

V. Phone/Fax

Practice location:
  • Phone: 505-948-8675
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: