Healthcare Provider Details

I. General information

NPI: 1619482064
Provider Name (Legal Business Name): SUNSHINE KIDS THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 04/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 S MAIN ST STE A
BELEN NM
87002-3503
US

IV. Provider business mailing address

412 VALLEJOS RD NE
LOS LUNAS NM
87031-7774
US

V. Phone/Fax

Practice location:
  • Phone: 505-321-5371
  • Fax:
Mailing address:
  • Phone: 505-321-5371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number4515
License Number StateNM

VIII. Authorized Official

Name: KATIE JIRON
Title or Position: PHYSICAL THERAPIST
Credential: DPT
Phone: 505-321-5371