Healthcare Provider Details

I. General information

NPI: 1518504885
Provider Name (Legal Business Name): DOUGLAS RICHARD SPENCE CERTIFIED TEACHER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 LEOPOLDO RD NW
ALBUQUERQUE NM
87104-2728
US

IV. Provider business mailing address

PO BOX 6151
ALBUQUERQUE NM
87197-6151
US

V. Phone/Fax

Practice location:
  • Phone: 505-767-5900
  • Fax:
Mailing address:
  • Phone: 505-344-4712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: