Healthcare Provider Details

I. General information

NPI: 1700244621
Provider Name (Legal Business Name): JOHN PHILIP DELA JUSTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2016
Last Update Date: 06/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 COORS BLVD NW STE K2
ALBUQUERQUE NM
87120-4761
US

IV. Provider business mailing address

3301 COORS BLVD NW
ALBUQUERQUE NM
87120-1292
US

V. Phone/Fax

Practice location:
  • Phone: 916-782-1212
  • Fax: 916-782-0695
Mailing address:
  • Phone: 505-843-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4781
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: