Provider Demographics
NPI:1558665893
Name:ANITA M. ROYBAL FAMILY AND PREVENTIVE HEALTH, LLC
Entity Type:Organization
Organization Name:ANITA M. ROYBAL FAMILY AND PREVENTIVE HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROYBAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-234-1612
Mailing Address - Street 1:1316 JACKIE RD SE STE 400
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1045
Mailing Address - Country:US
Mailing Address - Phone:505-234-1612
Mailing Address - Fax:505-234-1618
Practice Address - Street 1:1316 JACKIE RD SE STE 400
Practice Address - Street 2:SUITE 201
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1045
Practice Address - Country:US
Practice Address - Phone:505-234-1612
Practice Address - Fax:505-234-1618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-30
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM84110261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB2482OtherGROUP PTAN NUMBER
NMQ6735Medicaid
NMNMB2482OtherGROUP PTAN NUMBER
NMQ6735Medicaid
NMB26040Medicare UPIN