Provider Demographics
NPI:1639840861
Name:ORTIZ, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:M
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 249 #86086
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87103
Mailing Address - Country:US
Mailing Address - Phone:505-917-8018
Mailing Address - Fax:
Practice Address - Street 1:8875 COSTA VERDE BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-6656
Practice Address - Country:US
Practice Address - Phone:505-917-8018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility