=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063573509
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANDIA HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2006
-----------------------------------------------------
Last Update Date | 04/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 481 SANDIA LOOP
-----------------------------------------------------
City | BERNALILLO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87004-7076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-867-4487
-----------------------------------------------------
Fax | 505-771-5126
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 VASSAR DR NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87106-2725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-248-7711
-----------------------------------------------------
Fax | 505-248-7701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MARIA RICKERT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-248-4062
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------