Healthcare Provider Details

I. General information

NPI: 1164518114
Provider Name (Legal Business Name): MICHAEL W. RASCH C.P.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 04/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1691 GALISTEO ST SUITE B
SANTA FE NM
87505-4780
US

IV. Provider business mailing address

1691 GALISTEO STREET SUITE B
SANTA FE
87505
UM

V. Phone/Fax

Practice location:
  • Phone: 505-820-2390
  • Fax: 505-820-2392
Mailing address:
  • Phone: 505-820-2390
  • Fax: 505-820-2392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License NumberCPO 1456
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: