Healthcare Provider Details

I. General information

NPI: 1871048074
Provider Name (Legal Business Name): DWAYNE MACIAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2016
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 W MALONEY AVE
GALLUP NM
87301-5489
US

IV. Provider business mailing address

15 APEX DR
HIGHLAND IL
62249-1282
US

V. Phone/Fax

Practice location:
  • Phone: 505-488-2620
  • Fax: 505-488-2668
Mailing address:
  • Phone: 618-651-0444
  • Fax: 618-441-0482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number1619
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: