Healthcare Provider Details

I. General information

NPI: 1215044391
Provider Name (Legal Business Name): CHRISTOPHER WILLIAM SOVEREIGN LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 CARDENAS DR NE SUITE 204
ALBUQUERQUE NM
87110-6650
US

IV. Provider business mailing address

1101 CARDENAS DR NE SUITE 204
ALBUQUERQUE NM
87110-6650
US

V. Phone/Fax

Practice location:
  • Phone: 505-254-0022
  • Fax: 505-254-0022
Mailing address:
  • Phone: 505-254-0022
  • Fax: 505-254-0022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number923
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: