Healthcare Provider Details

I. General information

NPI: 1245699073
Provider Name (Legal Business Name): MIDORI M BRANCH LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 LOUISIANA BLVD SE APT C
ALBUQUERQUE NM
87108-5139
US

IV. Provider business mailing address

933 LOUISIANA BLVD SE APT C
ALBUQUERQUE NM
87108-5139
US

V. Phone/Fax

Practice location:
  • Phone: 505-717-9336
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7659
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: