Healthcare Provider Details

I. General information

NPI: 1538764717
Provider Name (Legal Business Name): DONALD OBRIEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3465 MCNUTT RD
SUNLAND PARK NM
88063-9056
US

IV. Provider business mailing address

3465 MCNUTT RD
SUNLAND PARK NM
88063-9056
US

V. Phone/Fax

Practice location:
  • Phone: 575-915-1338
  • Fax:
Mailing address:
  • Phone: 575-915-1338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: