Healthcare Provider Details

I. General information

NPI: 1831367093
Provider Name (Legal Business Name): MR. DEMOSTHENES STEPHEN METARELIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DEMO METARELIS

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 02/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8006 MENAUL NE MASSAGE THERAPY WITH LOVE AT ALIVE & WELL CENTER
ALBUQUERQUE NM
87110-4608
US

IV. Provider business mailing address

829 CLAUDINE NE MASSAGE THERAPY WITH LOVE
ALBUQUERQUE NM
87123-1224
US

V. Phone/Fax

Practice location:
  • Phone: 505-271-5483
  • Fax:
Mailing address:
  • Phone: 505-296-4396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2950
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: