Provider Demographics
NPI:1053712190
Name:LESLIE J ARCHULETA
Entity type:Organization
Organization Name:LESLIE J ARCHULETA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED NUTRITIONIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:JADE
Authorized Official - Last Name:ARCHULETA
Authorized Official - Suffix:
Authorized Official - Credentials:LN
Authorized Official - Phone:505-980-1743
Mailing Address - Street 1:100 SUN AVE NE
Mailing Address - Street 2:STE 650
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4659
Mailing Address - Country:US
Mailing Address - Phone:505-835-6759
Mailing Address - Fax:
Practice Address - Street 1:100 SUN AVE NE
Practice Address - Street 2:STE 650
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4659
Practice Address - Country:US
Practice Address - Phone:505-980-1743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-09
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLN-0959133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty