Healthcare Provider Details

I. General information

NPI: 1720099559
Provider Name (Legal Business Name): MYOFASCIAL REHABILITATION CENTER, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4308 CARLISLE BLVD NE SUITE 207
ALBUQUERQUE NM
87107-4856
US

IV. Provider business mailing address

PO BOX 91763
ALBUQUERQUE NM
87199-1763
US

V. Phone/Fax

Practice location:
  • Phone: 505-872-3100
  • Fax: 505-872-2600
Mailing address:
  • Phone: 505-872-3100
  • Fax: 505-872-2600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4498
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2193
License Number StateNM

VIII. Authorized Official

Name: MR. GEORGE SERGIO PELLEGRINO
Title or Position: VICE PRESIDENT
Credential: LMT, CMTPT
Phone: 505-872-3100