Provider Demographics
NPI:1962194563
Name:DEL RIO-CHACON, IRERI GUADALUPE (COTA/L)
Entity type:Individual
Prefix:
First Name:IRERI
Middle Name:GUADALUPE
Last Name:DEL RIO-CHACON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 SLOAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:NM
Mailing Address - Zip Code:88230-9737
Mailing Address - Country:US
Mailing Address - Phone:575-815-8500
Mailing Address - Fax:
Practice Address - Street 1:18 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-4023
Practice Address - Country:US
Practice Address - Phone:575-739-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOTA3934224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant