Healthcare Provider Details

I. General information

NPI: 1316097744
Provider Name (Legal Business Name): ROBERT PHILLIP VELARDE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N 2ND ST
GRANTS NM
87020-2507
US

IV. Provider business mailing address

6128 VIA CORTA DEL SUR NW
ALBUQUERQUE NM
87120-5014
US

V. Phone/Fax

Practice location:
  • Phone: 505-285-2614
  • Fax: 505-287-8487
Mailing address:
  • Phone: 505-899-3532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2744
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: