Healthcare Provider Details

I. General information

NPI: 1245362607
Provider Name (Legal Business Name): MARCIA H TRUJILLO LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 N PRINCE ST STE C
CLOVIS NM
88101-3843
US

IV. Provider business mailing address

1629 S AVENUE C
PORTALES NM
88130-7207
US

V. Phone/Fax

Practice location:
  • Phone: 505-714-4395
  • Fax:
Mailing address:
  • Phone: 505-226-0045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number5327
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: