Healthcare Provider Details

I. General information

NPI: 1245418367
Provider Name (Legal Business Name): MARYBETH PLUMMER PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2403 SAN MATEO BLVD NE W-24
ALBUQUERQUE NM
87110-4058
US

IV. Provider business mailing address

2403 SAN MATEO BLVD NE W-24
ALBUQUERQUE NM
87110-4058
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-6278
  • Fax: 505-266-0799
Mailing address:
  • Phone: 505-268-6278
  • Fax: 505-266-0799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number743
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: