Provider Demographics
NPI:1588045033
Name:DIETITIANSABQ
Entity Type:Organization
Organization Name:DIETITIANSABQ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KEYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-273-2512
Mailing Address - Street 1:5203 JUAN TABO BLVD NE
Mailing Address - Street 2:SUITE 2E
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2683
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5203 JUAN TABO BLVD NE
Practice Address - Street 2:SUITE 2E
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2683
Practice Address - Country:US
Practice Address - Phone:505-266-6121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EATING DISORDERS TREATMENT CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty