Healthcare Provider Details

I. General information

NPI: 1831635580
Provider Name (Legal Business Name): MR. MARK JARAMILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 LUNA AVE SE
LOS LUNAS NM
87031-6814
US

IV. Provider business mailing address

50 ANDRES SANCHEZ RD
BELEN NM
87002-8193
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-9636
  • Fax:
Mailing address:
  • Phone: 505-859-2057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3652
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: