Healthcare Provider Details

I. General information

NPI: 1396718276
Provider Name (Legal Business Name): SUSAN MARY MILES RDMS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 RODEO LN SUITE B3
SANTA FE NM
87507-4890
US

IV. Provider business mailing address

21 BROOKSWAY
SANTA FE NM
87508-9377
US

V. Phone/Fax

Practice location:
  • Phone: 505-438-0303
  • Fax:
Mailing address:
  • Phone: 505-983-5653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License NumberNOT APPLICABLE
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: