Healthcare Provider Details

I. General information

NPI: 1104538958
Provider Name (Legal Business Name): KIDS ROADS AND SKIES MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2022
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 COUNTY ROAD A4A
SAPELLO NM
87745-5002
US

IV. Provider business mailing address

21 COUNTY ROAD A4A
SAPELLO NM
87745-5002
US

V. Phone/Fax

Practice location:
  • Phone: 505-429-5846
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: NANCY WRIGHT
Title or Position: OWNER / PROVIDER
Credential: MD
Phone: 505-429-5846