Healthcare Provider Details

I. General information

NPI: 1609290915
Provider Name (Legal Business Name): GEORGE BOTELLO ASSOCIATES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 S GARDEN AVE
ROSWELL NM
88203-6866
US

IV. Provider business mailing address

202 E EARLL DR STE 200
PHOENIX AZ
85012-2647
US

V. Phone/Fax

Practice location:
  • Phone: 575-623-1480
  • Fax: 575-622-3325
Mailing address:
  • Phone: 575-623-1480
  • Fax: 575-622-3325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: