Healthcare Provider Details

I. General information

NPI: 1629125372
Provider Name (Legal Business Name): ANIMAS VALLEY BACK CENRTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 FARMINGTON AVE BLDG. F.
FARMINGTON NM
87401-4559
US

IV. Provider business mailing address

2700 FARMINGTON AVE BLDG. F.
FARMINGTON NM
87401-4559
US

V. Phone/Fax

Practice location:
  • Phone: 505-325-3381
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number97-111
License Number StateNM

VIII. Authorized Official

Name: JEFF MOSLEY
Title or Position: OWNER
Credential:
Phone: 505-402-5020