Healthcare Provider Details

I. General information

NPI: 1659828416
Provider Name (Legal Business Name): JEROME GARCIA PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7108 GISELE DR NE
ALBUQUERQUE NM
87109-3798
US

IV. Provider business mailing address

7108 GISELE DR NE
ALBUQUERQUE NM
87109-3798
US

V. Phone/Fax

Practice location:
  • Phone: 505-400-9226
  • Fax:
Mailing address:
  • Phone: 505-400-9226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0911
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: