Healthcare Provider Details

I. General information

NPI: 1316086838
Provider Name (Legal Business Name): BILA ASHDLA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S SAINT FRANCIS DR SUITE C
SANTA FE NM
87501-2458
US

IV. Provider business mailing address

3439 NE SANDY BLVD PMB 375
PORTLAND OR
97232-1959
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-5667
  • Fax: 505-820-1632
Mailing address:
  • Phone: 503-593-9875
  • Fax: 503-282-3302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number89267
License Number StateNM

VIII. Authorized Official

Name: DR. EDWARD JOSEPH NEIDHARDT
Title or Position: PSYCHIATRIST
Credential: M.D.
Phone: 505-988-5667