Provider Demographics
NPI:1750837332
Name:ARCHIBEQUE, KAITLYN THERESE
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:THERESE
Last Name:ARCHIBEQUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 716
Mailing Address - Street 2:
Mailing Address - City:ALGODONES
Mailing Address - State:NM
Mailing Address - Zip Code:87001
Mailing Address - Country:US
Mailing Address - Phone:505-414-4565
Mailing Address - Fax:
Practice Address - Street 1:1370A HWY 313
Practice Address - Street 2:
Practice Address - City:ALGODONES
Practice Address - State:NM
Practice Address - Zip Code:87001
Practice Address - Country:US
Practice Address - Phone:505-414-4565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer