Healthcare Provider Details

I. General information

NPI: 1649412750
Provider Name (Legal Business Name): CHRYSTAL COPELAND LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2009
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10900 MENAUL BLVD NE STE A
ALBUQUERQUE NM
87112-2453
US

IV. Provider business mailing address

10900 MENAUL BLVD NE STE A
ALBUQUERQUE NM
87112-2453
US

V. Phone/Fax

Practice location:
  • Phone: 505-205-9910
  • Fax: 505-292-3181
Mailing address:
  • Phone: 505-205-9910
  • Fax: 505-292-3181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6324
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: