Healthcare Provider Details

I. General information

NPI: 1255778874
Provider Name (Legal Business Name): SW MYOFUNCTIONAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2013
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5317 DON MIGUEL PL SW
ALBUQUERQUE NM
87105-5410
US

IV. Provider business mailing address

5317 DON MIGUEL PL SW
ALBUQUERQUE NM
87105-5410
US

V. Phone/Fax

Practice location:
  • Phone: 505-550-6042
  • Fax:
Mailing address:
  • Phone: 505-550-6042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH12281
License Number StateNM

VIII. Authorized Official

Name: SANDRALUZ GONZALEZ
Title or Position: MYOFUNCTIONAL THERAPIST
Credential: RDH
Phone: 505-550-6042