Healthcare Provider Details

I. General information

NPI: 1891451084
Provider Name (Legal Business Name): MIA JADE PALOMARES LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2021
Last Update Date: 08/06/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 COLLEGE BLVD
FARMINGTON NM
87402-1773
US

IV. Provider business mailing address

404 S SCHWARTZ AVE APT 107
FARMINGTON NM
87401-1314
US

V. Phone/Fax

Practice location:
  • Phone: 505-599-8880
  • Fax:
Mailing address:
  • Phone: 915-781-5668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number888
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: