Provider Demographics
NPI:1972680593
Name:RIO GRANDE ORTHOTICS AND PROSTHETICS
Entity Type:Organization
Organization Name:RIO GRANDE ORTHOTICS AND PROSTHETICS
Other - Org Name:ADVANCED PROSTHETICS AND ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MAZON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-820-2390
Mailing Address - Street 1:1691 GALISTEO ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4780
Mailing Address - Country:US
Mailing Address - Phone:505-820-2390
Mailing Address - Fax:505-820-2392
Practice Address - Street 1:1691 GALISTEO ST
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4780
Practice Address - Country:US
Practice Address - Phone:505-820-2390
Practice Address - Fax:505-820-2392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM47951335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM84927054Medicaid
NM84927054Medicaid