Healthcare Provider Details

I. General information

NPI: 1144592874
Provider Name (Legal Business Name): RITA GRANBERRY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2012
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 LOMAS BLVD NE SUITE 111
ALBUQUERQUE NM
87112-5463
US

IV. Provider business mailing address

11700 ARROYO DE VIS NE
ALBUQUERQUE NM
87111-5748
US

V. Phone/Fax

Practice location:
  • Phone: 505-307-1447
  • Fax:
Mailing address:
  • Phone: 505-307-1447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7092
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: