Healthcare Provider Details

I. General information

NPI: 1396756987
Provider Name (Legal Business Name): FOUR CORNERS ARTIFICIAL LIMB & BRACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 W BROADWAY
FARMINGTON NM
87401-5910
US

IV. Provider business mailing address

653 W BROADWAY
FARMINGTON NM
87401-5910
US

V. Phone/Fax

Practice location:
  • Phone: 505-326-6305
  • Fax: 505-326-6325
Mailing address:
  • Phone: 505-326-6305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. JUSTIN HOWARD MARSHALL
Title or Position: OWNER, PRESIDENT
Credential:
Phone: 505-326-6305