Healthcare Provider Details

I. General information

NPI: 1497364780
Provider Name (Legal Business Name): RIO GRANDE FOOT & ANKLE SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 GALISTEO ST STE K-2
SANTA FE NM
87505-2143
US

IV. Provider business mailing address

PO BOX 540610
N SALT LAKE UT
84054-0610
US

V. Phone/Fax

Practice location:
  • Phone: 505-395-9575
  • Fax: 877-540-1253
Mailing address:
  • Phone: 801-505-0821
  • Fax: 801-505-0803

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 ELIZABETH DEITHLOFF
Title or Position: DPM/OWNER
Credential:
Phone: 505-395-9575