Healthcare Provider Details

I. General information

NPI: 1750538807
Provider Name (Legal Business Name): IVYROSE GONZALES MOTR/L,ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 SAN PEDRO DR NE STE 116
ALBUQUERQUE NM
87110-3364
US

IV. Provider business mailing address

12105 DAN PATCH RD SE
ALBUQUERQUE NM
87123-2196
US

V. Phone/Fax

Practice location:
  • Phone: 505-350-3069
  • Fax: 505-508-2305
Mailing address:
  • Phone: 505-350-3069
  • Fax: 505-508-2305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0805
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: