Provider Demographics
NPI:1063693141
Name:RIO BRAVO MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:RIO BRAVO MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROSYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-271-2727
Mailing Address - Street 1:1515 EUBANK BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-4112
Mailing Address - Country:US
Mailing Address - Phone:505-271-2727
Mailing Address - Fax:505-271-2828
Practice Address - Street 1:1515 EUBANK BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-4112
Practice Address - Country:US
Practice Address - Phone:505-271-2727
Practice Address - Fax:505-271-2828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-17
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM03123020002332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM49685082Medicaid
NM6040390001Medicare NSC