Healthcare Provider Details

I. General information

NPI: 1316072317
Provider Name (Legal Business Name): DARYL C WOOTEN A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 EL PASEO RD
LAS CRUCES NM
88001-6011
US

IV. Provider business mailing address

2522 LOS ALAMOS CT
LAS CRUCES NM
88011-1657
US

V. Phone/Fax

Practice location:
  • Phone: 505-527-9409
  • Fax: 505-527-9767
Mailing address:
  • Phone: 505-522-4949
  • Fax: 505-527-9767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number39
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: