Healthcare Provider Details

I. General information

NPI: 1750457834
Provider Name (Legal Business Name): ROGER RONALD COLLINS A.T., C., L. A. T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 S RIO GRANDE AVE
AZTEC NM
87410-2260
US

IV. Provider business mailing address

808 SPOTTED WOLF AVE
AZTEC NM
87410-2093
US

V. Phone/Fax

Practice location:
  • Phone: 505-334-9616
  • Fax: 505-334-7343
Mailing address:
  • Phone: 505-334-5119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number108
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: