Healthcare Provider Details

I. General information

NPI: 1184103475
Provider Name (Legal Business Name): JOHN GARRAHAN DALY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6020 CONSTITUTION AVE NE STE 4
ALBUQUERQUE NM
87110-5931
US

IV. Provider business mailing address

6020 CONSTITUTION AVE NE STE 4
ALBUQUERQUE NM
87110-5931
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-5099
  • Fax: 505-255-2406
Mailing address:
  • Phone: 505-255-5099
  • Fax: 505-255-2406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT866
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: