Healthcare Provider Details

I. General information

NPI: 1427323633
Provider Name (Legal Business Name): JUAN CARLOS ZAVALA MASSAGE THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JUAN CARLOS ZAVALA MASSAGE THERAPIST

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 ADAMS ST SE S.E.
ALBUQUERQUE NM
87108-2805
US

IV. Provider business mailing address

230 ADAMS STREET S.E.
ALBUQUERQUE NM
87108
US

V. Phone/Fax

Practice location:
  • Phone: 505-843-7492
  • Fax:
Mailing address:
  • Phone: 505-843-7492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberLMT 3032
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: