Healthcare Provider Details

I. General information

NPI: 1942568464
Provider Name (Legal Business Name): BRIDGET RENEE SANDERS LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 DR MARTIN LUTHER KING JR AVE NE
ALBUQUERQUE NM
87102-3619
US

IV. Provider business mailing address

911 S RIO GRANDE AVE
AZTEC NM
87410-2295
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-8966
  • Fax:
Mailing address:
  • Phone: 505-793-2471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA0681
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: