Healthcare Provider Details

I. General information

NPI: 1285462713
Provider Name (Legal Business Name): GABRIEL CORTEZ LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 S CLOVER DR STE 5
BAYFIELD CO
81122-8758
US

IV. Provider business mailing address

175 S CLOVER DR STE 5
BAYFIELD CO
81122-8758
US

V. Phone/Fax

Practice location:
  • Phone: 970-884-9779
  • Fax: 970-884-0847
Mailing address:
  • Phone: 970-884-9779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT.0026463
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: