Healthcare Provider Details

I. General information

NPI: 1609731728
Provider Name (Legal Business Name): BENJAMIN MADRID
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11701 FOX POINT AVE NE
ALBUQUERQUE NM
87112-1916
US

IV. Provider business mailing address

11701 FOX POINT AVE NE
ALBUQUERQUE NM
87112-1916
US

V. Phone/Fax

Practice location:
  • Phone: 720-312-1604
  • Fax:
Mailing address:
  • Phone: 720-312-1604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-2025-0333
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: