Healthcare Provider Details

I. General information

NPI: 1932808201
Provider Name (Legal Business Name): GILBERTO RIVERA BONILLA LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 02/27/2023
Certification Date: 02/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8125 MONTEREY EAST AVE NE
ALBUQUERQUE NM
87109-1733
US

IV. Provider business mailing address

PO BOX 94645
ALBUQUERQUE NM
87199-4645
US

V. Phone/Fax

Practice location:
  • Phone: 505-710-2603
  • Fax:
Mailing address:
  • Phone: 505-710-2603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8747
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: