Provider Demographics
NPI:1598142762
Name:RIO GRANDE NEUROSCIENCE LLC
Entity Type:Organization
Organization Name:RIO GRANDE NEUROSCIENCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-412-0545
Mailing Address - Street 1:600 CENTRAL AVE SE
Mailing Address - Street 2:SUITE 221
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3656
Mailing Address - Country:US
Mailing Address - Phone:505-345-9288
Mailing Address - Fax:505-212-0359
Practice Address - Street 1:600 CENTRAL AVE SE
Practice Address - Street 2:SUITE 221
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3656
Practice Address - Country:US
Practice Address - Phone:505-345-9288
Practice Address - Fax:505-212-0359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-27
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1147103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty