Healthcare Provider Details

I. General information

NPI: 1275052391
Provider Name (Legal Business Name): PETER RUEL PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 09/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 ELM ST NE
ALBUQUERQUE NM
87102-2500
US

IV. Provider business mailing address

1841 CHICOMA RD NE
RIO RANCHO NM
87144-2500
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-4700
  • Fax:
Mailing address:
  • Phone: 505-492-9897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-1203
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: