MEDICARE: TASKER HATCH ROWAN 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	122300000X	Dentist	3168	NM

General Provider Information

NPI Number	:	1750783502
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TASKER HATCH ROWAN LLC

Provider Business Mailing Address
First Line	:	325 S HIGLEY #130
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85296
Country	:	US
Telephone Number	:	505-850-3769
Fax Number	:	505-890-2949

Provider Business Practice Location Address
First Line	:	111 COORS BLVD NW STE E6
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87121-2009
Country	:	US
Telephone Number	:	505-892-9010
Fax Number	:	505-899-4804

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	EBONIE GONZALES
Credential	:
Telephone Number	:	505-850-3769

Provider Enumeration Date	:	09/24/2014
Last Update Date	:	05/24/2022

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