Healthcare Provider Details

I. General information

NPI: 1508389784
Provider Name (Legal Business Name): AZTEC SPA AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 07/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 W AZTEC BLVD STE 4
AZTEC NM
87410-1899
US

IV. Provider business mailing address

5200 VILLA VIEW DR APT 12A
FARMINGTON NM
87402-8255
US

V. Phone/Fax

Practice location:
  • Phone: 505-320-1850
  • Fax:
Mailing address:
  • Phone: 505-320-1850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8154
License Number StateNM

VIII. Authorized Official

Name: MS. TONI FARQUHARSON
Title or Position: OWNER
Credential: LMT
Phone: 505-320-1850