=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659805042
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INGRID YOGITA BUTLER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2017
-----------------------------------------------------
Last Update Date | 04/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11930 MENAUL BLVD NE SUITE 106A
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87112-2478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-414-7620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 20246
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87154-0246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-414-7620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SOLE PROPRIETOR
-----------------------------------------------------
Name | DR. INGRID YOGITA BUTLER
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 505-414-7620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 5899
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------