Provider Demographics
NPI:1174080626
Name:ISIDOR, CLEVEN
Entity type:Individual
Prefix:
First Name:CLEVEN
Middle Name:
Last Name:ISIDOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 PONDEROSA AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-3357
Mailing Address - Country:US
Mailing Address - Phone:845-553-4207
Mailing Address - Fax:
Practice Address - Street 1:454 CORONADO ST NE
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-8709
Practice Address - Country:US
Practice Address - Phone:505-866-0456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-83283163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool