Healthcare Provider Details

I. General information

NPI: 1649789942
Provider Name (Legal Business Name): ADRIENNE BROGDON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 09/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5305 HERITAGE CT. NE
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

5305 HERITAGE CT. NE
ALBUQUERQUE NM
87109
US

V. Phone/Fax

Practice location:
  • Phone: 505-822-5001
  • Fax: 505-274-7762
Mailing address:
  • Phone: 505-822-5001
  • Fax: 505-274-7762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8616
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: