Healthcare Provider Details

I. General information

NPI: 1407428303
Provider Name (Legal Business Name): MALACHI JACOBY SEGURA OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 CANDELARIA RD NE STE E
ALBUQUERQUE NM
87107-1952
US

IV. Provider business mailing address

11317 BAJA DR NE
ALBUQUERQUE NM
87111-2609
US

V. Phone/Fax

Practice location:
  • Phone: 505-200-9962
  • Fax:
Mailing address:
  • Phone: 505-429-8841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-2023-0089
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: