Healthcare Provider Details

I. General information

NPI: 1780835504
Provider Name (Legal Business Name): ROGER L LEONARD RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 01/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#85 WEST HWY 22
SANTO DOMINGO NM
87052
US

IV. Provider business mailing address

PO BOX 340
SANTA FE NM
87052
US

V. Phone/Fax

Practice location:
  • Phone: 505-465-3060
  • Fax:
Mailing address:
  • Phone: 505-465-3060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberR54222
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: