Healthcare Provider Details

I. General information

NPI: 1538657135
Provider Name (Legal Business Name): LILY ARITE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2018
Last Update Date: 04/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 SAINT ST NE
ALBUQUERQUE NM
87112-2857
US

IV. Provider business mailing address

1845 SAINT ST NE
ALBUQUERQUE NM
87112-2857
US

V. Phone/Fax

Practice location:
  • Phone: 505-977-3843
  • Fax:
Mailing address:
  • Phone: 505-977-3843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1499
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: