Healthcare Provider Details

I. General information

NPI: 1013425743
Provider Name (Legal Business Name): BLACKTHORNE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 CARLISLE BLVD NE SUITE D
ALBUQUERQUE NM
87107-5633
US

IV. Provider business mailing address

624 DOUGLAS MACARTHUR RD NW
ALBUQUERQUE NM
87107
US

V. Phone/Fax

Practice location:
  • Phone: 505-977-0666
  • Fax:
Mailing address:
  • Phone: 505-977-0666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: RHYDIAN BLACKTHORNE
Title or Position: OWNER/CEO
Credential: LMT
Phone: 505-977-0666