Healthcare Provider Details

I. General information

NPI: 1679725667
Provider Name (Legal Business Name): SOUTHWEST MYOTHERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4103 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1102
US

IV. Provider business mailing address

4103 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1102
US

V. Phone/Fax

Practice location:
  • Phone: 505-830-3585
  • Fax: 505-830-3584
Mailing address:
  • Phone: 505-830-3585
  • Fax: 505-830-3584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1707
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4024
License Number StateNM

VIII. Authorized Official

Name: MS. KAREN P. CARBONNEAU
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-830-3585