Healthcare Provider Details

I. General information

NPI: 1679706964
Provider Name (Legal Business Name): CHRISTOPHER SHANTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 09/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3013 FORAKER PL NW
ALBUQUERQUE NM
87107-1280
US

IV. Provider business mailing address

PO BOX 30363
ALBUQUERQUE NM
87190-0363
US

V. Phone/Fax

Practice location:
  • Phone: 505-440-1128
  • Fax:
Mailing address:
  • Phone: 505-232-7177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: