Healthcare Provider Details

I. General information

NPI: 1578429353
Provider Name (Legal Business Name): BRYAN ALEXIS RASCON-ANDRADE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/24/2025
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 MARQUEZ PL UNIT 106B
SANTA FE NM
87505-1833
US

IV. Provider business mailing address

1408 8TH ST
ALAMOGORDO NM
88310-5115
US

V. Phone/Fax

Practice location:
  • Phone: 866-608-5560
  • Fax:
Mailing address:
  • Phone: 866-608-5560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: