Healthcare Provider Details

I. General information

NPI: 1669708491
Provider Name (Legal Business Name): MATTHEW HORNBACK DPT, LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax:
Mailing address:
  • Phone: 505-722-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number62408
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number16338
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: