Healthcare Provider Details

I. General information

NPI: 1215112909
Provider Name (Legal Business Name): CAROLYN D. BENALLY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2008
Last Update Date: 01/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 SAN CARLOS RD SW
ALBUQUERQUE NM
87104-1041
US

IV. Provider business mailing address

1430 SAN CARLOS RD SW
ALBUQUERQUE NM
87104-1041
US

V. Phone/Fax

Practice location:
  • Phone: 505-553-1093
  • Fax:
Mailing address:
  • Phone: 505-553-1093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0436
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: