Provider Demographics
NPI:1578009296
Name:RIO GRANDE ORTHOTICS AND PROSTHETICS
Entity Type:Organization
Organization Name:RIO GRANDE ORTHOTICS AND PROSTHETICS
Other - Org Name:ADVANCED PROSTHETICS AND ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MAZON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-820-2390
Mailing Address - Street 1:1010 LEAD AVE SE
Mailing Address - Street 2:STE 400
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-5214
Mailing Address - Country:US
Mailing Address - Phone:505-247-0430
Mailing Address - Fax:505-247-0653
Practice Address - Street 1:1010 LEAD AVE SE
Practice Address - Street 2:STE 400
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-5214
Practice Address - Country:US
Practice Address - Phone:505-247-0430
Practice Address - Fax:505-247-0653
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIO GRANDE ORTHOTICS AND PROSTHETICS DBA ADVANCED PROSTHETICS AND ORTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-19
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCOM-2016-341856335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM38400839Medicaid