Healthcare Provider Details

I. General information

NPI: 1033895602
Provider Name (Legal Business Name): RYAN BLAKE PRIDEMORE LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 MESA GRANDE DR
LAS CRUCES NM
88011-6017
US

IV. Provider business mailing address

3402 BIXLER DR APT 2202
LAS CRUCES NM
88012-5114
US

V. Phone/Fax

Practice location:
  • Phone: 423-312-1031
  • Fax:
Mailing address:
  • Phone: 423-312-1031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-2024-0006
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT9424
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: