Provider Demographics
NPI:1336495720
Name:ROYBAL, JOHN
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:ROYBAL
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 1:2001 CHAMISA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3441
Mailing Address - Country:US
Mailing Address - Phone:505-982-2129
Mailing Address - Fax:505-992-1149
Practice Address - Street 1:2001 CHAMISA ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3441
Practice Address - Country:US
Practice Address - Phone:505-982-2129
Practice Address - Fax:505-992-1149
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NML09836164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse