=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639667389
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CACHOMED HEALTH PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2018
-----------------------------------------------------
Last Update Date | 10/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 531 HARKLE RD STE B
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-4753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-954-1459
-----------------------------------------------------
Fax | 505-983-7571
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 CORDOVA PL # 86
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-1725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-954-1459
-----------------------------------------------------
Fax | 505-466-1729
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANIEL RADUNSKY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 505-954-1459
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------