Healthcare Provider Details

I. General information

NPI: 1740605625
Provider Name (Legal Business Name): MRS. CHRISTINA ROSE MASTERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. CHRISTY ROSE MASTERSON

II. Dates (important events)

Enumeration Date: 02/28/2014
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3017 N. PRINCE SUITE B
CLOVIS NM
88101-3120
US

IV. Provider business mailing address

2008 COLONIAL PKWY
CLOVIS NM
88101-3120
US

V. Phone/Fax

Practice location:
  • Phone: 575-693-2838
  • Fax:
Mailing address:
  • Phone: 575-693-2838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7711
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: