Healthcare Provider Details

I. General information

NPI: 1386118933
Provider Name (Legal Business Name): XIMENA DE LOS RIOS BUSTILLOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2019
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 OFFICE COURT DR STE 706
SANTA FE NM
87507-4958
US

IV. Provider business mailing address

7325 RIO DEL SOL
SANTA FE NM
87507-7315
US

V. Phone/Fax

Practice location:
  • Phone: 505-490-9310
  • Fax:
Mailing address:
  • Phone: 505-490-9310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number515265180
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: