Healthcare Provider Details

I. General information

NPI: 1053729236
Provider Name (Legal Business Name): REFORM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10917 CARTAGENA AVE SW
ALBUQUERQUE NM
87121-8274
US

IV. Provider business mailing address

10917 CARTAGENA AVE SW
ALBUQUERQUE NM
87121-8274
US

V. Phone/Fax

Practice location:
  • Phone: 505-639-1400
  • Fax:
Mailing address:
  • Phone: 505-639-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE MARTIN
Title or Position: MASSAGE THERAPIST
Credential: L.M.T
Phone: 505-639-1400