MEDICARE: GRD HEALTH CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	444	NM

General Provider Information

NPI Number	:	1124315577
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRD HEALTH CLINIC LLC

Provider Business Mailing Address
First Line	:	510 N PASEO DE ONATE
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2618
Country	:	US
Telephone Number	:	505-753-3369
Fax Number	:	505-753-4006

Provider Business Practice Location Address
First Line	:	510 N PASEO DE ONATE
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2618
Country	:	US
Telephone Number	:	505-753-3369
Fax Number	:	505-753-4006

Authorized Official
Title or Position	:	DOMRX2
Name	:	MRS. JIWAN KHALSA
Credential	:	DOM RX2
Telephone Number	:	505-753-3369

Provider Enumeration Date	:	07/06/2011
Last Update Date	:	07/06/2011

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Directions to “GRD HEALTH CLINIC LLC ” Practice Location

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