Healthcare Provider Details

I. General information

NPI: 1598119752
Provider Name (Legal Business Name): SAM GARRETT ARREDONDO ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 WELLS ST
LAS CRUCES NM
88003-1304
US

IV. Provider business mailing address

2775 N ROADRUNNER PKWY #3202
LAS CRUCES NM
88011-8112
US

V. Phone/Fax

Practice location:
  • Phone: 575-646-6064
  • Fax:
Mailing address:
  • Phone: 559-679-7510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number659
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: