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General NPI Number Information
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NPI Number | 1740556893
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Entity Type | Organization
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Legal Business Name | KIDSBRIDGE
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Dates
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Enumeration Date | 03/22/2012
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Last Update Date | 03/22/2012
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Provider Practice Location Address
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Address Line | 608 BLEDSOE RD NW
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City | LOS RANCHOS
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State | NM
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Zip | 87107-6219
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Country | US
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Telephone | 505-908-0717
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Fax | 505-344-5553
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Provider Business Mailing Address
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Address Line | 1104 SALAMANCA ST NW
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City | LOS RANCHOS
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State | NM
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Zip | 87107-5626
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Country | US
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Telephone | 505-908-0717
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Fax | 505-344-5553
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Authorized Official
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Title or Position | OWNER / OPERATOR
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Name | MRS. KRISTEN S WIESE
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Credential | MA OTR/L
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Telephone | 505-908-0717
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 2414
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License Number State | NM
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