Healthcare Provider Details

I. General information

NPI: 1982016945
Provider Name (Legal Business Name): NICOLE CHAMBERLAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 EUBANK BLVD NE STE 2
ALBUQUERQUE NM
87112-5300
US

IV. Provider business mailing address

4918 ARROYO CHAMISA RD NE
ALBUQUERQUE NM
87111-3716
US

V. Phone/Fax

Practice location:
  • Phone: 505-280-5944
  • Fax: 505-298-7724
Mailing address:
  • Phone: 505-280-5944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number7736
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: