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General NPI Number Information
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NPI Number | 1659800894
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Entity Type | Organization
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Legal Business Name | INTEGRATED HEALTHCARE
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Dates
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Enumeration Date | 06/10/2017
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Last Update Date | 06/10/2017
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Provider Practice Location Address
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Address Line | 4101 BARBARA LOOP SE STE C
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City | RIO RANCHO
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State | NM
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Zip | 87124-1011
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Country | US
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Telephone | 505-994-4503
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Fax | 505-891-1495
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Provider Business Mailing Address
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Address Line | 4101 BARBARA LOOP SE STE C
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City | RIO RANCHO
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State | NM
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Zip | 87124-1011
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Country | US
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Telephone | 505-994-4503
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Fax | 505-891-1495
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Authorized Official
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Title or Position | OWNER
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Name | JACQUELINE EVA WILLIS
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Credential | NP
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Telephone | 505-994-4503
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | CNP-0216
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License Number State | NM
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