Healthcare Provider Details

I. General information

NPI: 1457974222
Provider Name (Legal Business Name): TELE-PEDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 LLANO ST STE B
SANTA FE NM
87505-5415
US

IV. Provider business mailing address

1704 LLANO ST STE B - POB: 1414
SANTA FE NM
87505
US

V. Phone/Fax

Practice location:
  • Phone: 757-667-8898
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MISHA HARRIS
Title or Position: CO-FOUNDER
Credential: NP
Phone: 757-667-8898