Healthcare Provider Details

I. General information

NPI: 1326525809
Provider Name (Legal Business Name): ERIC THOMAS MARES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 07/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 PASEO DEL CANON W STE A
TAOS NM
87571-6943
US

IV. Provider business mailing address

PO BOX 94508
ALBUQUERQUE NM
87199-4508
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-5857
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-09282
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: