Provider Demographics
NPI:1801003231
Name:PETROGLYPH PATHOLOGY SERVICES, LLC
Entity Type:Organization
Organization Name:PETROGLYPH PATHOLOGY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MUELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-924-0209
Mailing Address - Street 1:640 QUANTUM RD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-4506
Mailing Address - Country:US
Mailing Address - Phone:505-924-0209
Mailing Address - Fax:505-924-0210
Practice Address - Street 1:640 QUANTUM RD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4506
Practice Address - Country:US
Practice Address - Phone:505-924-0209
Practice Address - Fax:505-924-0210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty