Healthcare Provider Details

I. General information

NPI: 1679071757
Provider Name (Legal Business Name): JOSE ALBERT VALDEZ LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 GUSDORF RD
TAOS NM
87571-6282
US

IV. Provider business mailing address

PO BOX 158
ESPANOLA NM
87532-0158
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-3603
  • Fax: 575-758-1058
Mailing address:
  • Phone: 505-753-7218
  • Fax: 505-747-7396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number0088761
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: