Healthcare Provider Details

I. General information

NPI: 1174152615
Provider Name (Legal Business Name): MATTHEW JACOB SENA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 04/06/2020
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10101 LAGRIMA DE ORO RD NE
ALBUQUERQUE NM
87111-6022
US

IV. Provider business mailing address

7456 SKY COURT CIR NE
ALBUQUERQUE NM
87110-4537
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-1231
  • Fax:
Mailing address:
  • Phone: 505-267-6634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1649
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: