Healthcare Provider Details

I. General information

NPI: 1407187404
Provider Name (Legal Business Name): NARA SHEDD LMT 5917
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 DARTMOUTH DR SE
ALBUQUERQUE NM
87106-2219
US

IV. Provider business mailing address

201 DARTMOUTH DR SE
ALBUQUERQUE NM
87106-2219
US

V. Phone/Fax

Practice location:
  • Phone: 505-975-4823
  • Fax:
Mailing address:
  • Phone: 505-975-4823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number5917
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: