Provider Demographics
NPI:1356619597
Name:ROMERO, GRACE J (LMT, MMT 7172)
Entity type:Individual
Prefix:MS
First Name:GRACE
Middle Name:J
Last Name:ROMERO
Suffix:
Gender:F
Credentials:LMT, MMT 7172
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 MOON STREET. NE SUITE 300
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112
Mailing Address - Country:US
Mailing Address - Phone:505-323-2114
Mailing Address - Fax:
Practice Address - Street 1:1701 MOON ST NE STE 300
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-3900
Practice Address - Country:US
Practice Address - Phone:505-323-2114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-02
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7172174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist