Healthcare Provider Details

I. General information

NPI: 1770050189
Provider Name (Legal Business Name): OUTLAST THERAPEUTICS LTD. CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6211 SAN MATEO BLVD NE STE 200
ALBUQUERQUE NM
87109-3534
US

IV. Provider business mailing address

6104 MARTA RD NW
ALBUQUERQUE NM
87114-3897
US

V. Phone/Fax

Practice location:
  • Phone: 505-373-2833
  • Fax:
Mailing address:
  • Phone: 505-967-6901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: STEPHANI MCCOY
Title or Position: OWNER
Credential:
Phone: 505-967-6901