Provider Demographics
NPI:1235466103
Name:GRINE, ARCHIE
Entity Type:Individual
Prefix:MR
First Name:ARCHIE
Middle Name:
Last Name:GRINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 SILVER AVE SE
Mailing Address - Street 2:SUITE F
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-2748
Mailing Address - Country:US
Mailing Address - Phone:505-255-1804
Mailing Address - Fax:505-265-4446
Practice Address - Street 1:4300 SILVER AVE SE
Practice Address - Street 2:SUITE F
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2748
Practice Address - Country:US
Practice Address - Phone:505-255-1804
Practice Address - Fax:505-265-4446
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-12
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1348101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health