Healthcare Provider Details

I. General information

NPI: 1811587959
Provider Name (Legal Business Name): SURI SADAI RINCON MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 01/22/2021
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 OFFICE COURT DR STE 603
SANTA FE NM
87507-4905
US

IV. Provider business mailing address

4001 OFFICE COURT DR STE 603
SANTA FE NM
87507-4905
US

V. Phone/Fax

Practice location:
  • Phone: 505-830-1871
  • Fax: 505-835-2270
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-11747
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: