Organization
KIDSBRIDGE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. KRISTEN S WIESE MA OTR/L (OWNER / OPERATOR)
(505) 908-0717
Entity
Organization
Contact information
Practice address
608 BLEDSOE RD NW, LOS RANCHOS, NM 87107-6219
(505) 908-0717
(505) 344-5553
Mailing address
1104 SALAMANCA ST NW, LOS RANCHOS, NM 87107-5626
(505) 908-0717
(505) 344-5553
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
2414
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1841473527
INDIVIDUAL NPI
NM
Enumeration date
03/22/2012
Last updated
03/22/2012
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