Healthcare Provider Details

I. General information

NPI: 1902624026
Provider Name (Legal Business Name): MIAE CHANTILLY CHAVEZ LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5115 COORS BLVD NW
ALBUQUERQUE NM
87120-1900
US

IV. Provider business mailing address

2101 TORRENT DR NW
ALBUQUERQUE NM
87120-7122
US

V. Phone/Fax

Practice location:
  • Phone: 505-897-6560
  • Fax:
Mailing address:
  • Phone: 808-283-8880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAT-10851
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberNM-2024-0097
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: