Healthcare Provider Details

I. General information

NPI: 1578242558
Provider Name (Legal Business Name): ALEISHA LUNDSTROM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 07/17/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 RODEO GROUND ROAD GRANTS, NM 87020
GRANTS NM
87020
US

IV. Provider business mailing address

PO BOX 27
GRANTS NM
87020-0027
US

V. Phone/Fax

Practice location:
  • Phone: 505-270-9733
  • Fax:
Mailing address:
  • Phone: 505-270-9733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ALEISHA LUNDSTROM
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: MPT
Phone: 505-270-9733