Healthcare Provider Details

I. General information

NPI: 1003450404
Provider Name (Legal Business Name): ROSALBA I PONCE REYES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2019
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187B SUNRISE RD
SANTA FE NM
87507-3781
US

IV. Provider business mailing address

187B SUNRISE RD
SANTA FE NM
87507-3781
US

V. Phone/Fax

Practice location:
  • Phone: 505-577-7685
  • Fax:
Mailing address:
  • Phone: 505-577-7685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: