Healthcare Provider Details

I. General information

NPI: 1528517224
Provider Name (Legal Business Name): DARREL DRYDEN LAT, ATC, CSCS, FMS1
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 MOUNTAIN VIEW DR
GALLUP NM
87301-5643
US

IV. Provider business mailing address

1903 MOUNTAIN VIEW DR
GALLUP NM
87301-5643
US

V. Phone/Fax

Practice location:
  • Phone: 605-269-1892
  • Fax:
Mailing address:
  • Phone: 605-269-1892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number678
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: