Provider Demographics
NPI:1639505712
Name:RIO GRANDE GERIATRICS AND FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:RIO GRANDE GERIATRICS AND FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:505-220-3873
Mailing Address - Street 1:8328 CASCADE PARK AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-6523
Mailing Address - Country:US
Mailing Address - Phone:505-220-3873
Mailing Address - Fax:505-792-5222
Practice Address - Street 1:8328 CASCADE PARK AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-6523
Practice Address - Country:US
Practice Address - Phone:505-220-3873
Practice Address - Fax:505-792-5222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontologyGroup - Multi-Specialty