MEDICARE: MCKENZIE CORDOVA

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1588208508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MCKENZIE CORDOVA

Provider Business Mailing Address
First Line	:	6897 AUGUSTA HILLS DR NE
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87144-8604
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6897 AUGUSTA HILLS DR NE
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87144-8604
Country	:	US
Telephone Number	:	505-867-1021
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2019
Last Update Date	:	11/01/2019

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Directions to “ MCKENZIE CORDOVA ” Practice Location

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