Healthcare Provider Details

I. General information

NPI: 1568915064
Provider Name (Legal Business Name): KENT SALAZAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2016
Last Update Date: 08/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8612 SUNDORO PL NW
ALBUQUERQUE NM
87120-1070
US

IV. Provider business mailing address

8612 SUNDORO PL NW
ALBUQUERQUE NM
87120-1070
US

V. Phone/Fax

Practice location:
  • Phone: 505-977-5589
  • Fax:
Mailing address:
  • Phone: 505-977-5589
  • 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: