Healthcare Provider Details

I. General information

NPI: 1285300673
Provider Name (Legal Business Name): RIO GRANDE FOOT & ANKLE SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 BRUNN SCHOOL RD
SANTA FE NM
87505-1102
US

IV. Provider business mailing address

2561 S 1560 W STE B
WOODS CROSS UT
84087-2361
US

V. Phone/Fax

Practice location:
  • Phone: 505-395-9575
  • Fax: 877-540-1253
Mailing address:
  • Phone: 801-505-0821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE DEITHLOFF
Title or Position: DPM
Credential:
Phone: 801-643-2921