Healthcare Provider Details

I. General information

NPI: 1841445574
Provider Name (Legal Business Name): GREG ALLEN KIRK PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2008
Last Update Date: 11/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 REDROCK DR
GALLUP NM
87301-5683
US

IV. Provider business mailing address

3303 CHURCH ROCK ST
GALLUP NM
87301-4505
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-7136
  • Fax:
Mailing address:
  • Phone: 505-863-6464
  • Fax: 505-726-6719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2734
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: