Healthcare Provider Details

I. General information

NPI: 1942255542
Provider Name (Legal Business Name): LIAT ALKON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 09/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 RAYMAC RD SW ALBUQUERQUE PUBLIC SCHOOL - PARK MIDDLE SCHOOL
ALBUQUERQUE NM
87105-6843
US

IV. Provider business mailing address

7318 GENE AVE NE
ALBUQUERQUE NM
87109-1849
US

V. Phone/Fax

Practice location:
  • Phone: 505-296-9521
  • Fax: 505-296-2200
Mailing address:
  • Phone: 505-881-4480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3120
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: