Healthcare Provider Details

I. General information

NPI: 1972680593
Provider Name (Legal Business Name): RIO GRANDE ORTHOTICS AND PROSTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
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 ST SUITE B
SANTA FE NM
87505-4780
US

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 TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number47951
License Number StateNM

VIII. Authorized Official

Name: MR. FOREST SEXTON
Title or Position: MEMBER
Credential:
Phone: 541-531-0439