Healthcare Provider Details

I. General information

NPI: 1164842746
Provider Name (Legal Business Name): OMAR FERCHA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 04/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 MESA GRANDE AVE
LAS CRUCES NM
88011
US

IV. Provider business mailing address

5400 MESA GRANDE AVE
LAS CRUCES NM
88011
US

V. Phone/Fax

Practice location:
  • Phone: 575-527-9430
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number487
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: