Healthcare Provider Details

I. General information

NPI: 1932276474
Provider Name (Legal Business Name): ROBERT MARANAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N MAIN ST
BELEN NM
87002-3720
US

IV. Provider business mailing address

520 N MAIN ST
BELEN NM
87002-3720
US

V. Phone/Fax

Practice location:
  • Phone: 505-966-1506
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberT7505
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: