Healthcare Provider Details

I. General information

NPI: 1568711943
Provider Name (Legal Business Name): DAVID OVERSTREET
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 10TH ST
ALAMOGORDO NM
88310-5047
US

IV. Provider business mailing address

1600 10TH ST
ALAMOGORDO NM
88310-5047
US

V. Phone/Fax

Practice location:
  • Phone: 575-439-5425
  • Fax: 575-439-5425
Mailing address:
  • Phone: 575-439-5425
  • Fax: 575-439-5425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: