Healthcare Provider Details

I. General information

NPI: 1639518822
Provider Name (Legal Business Name): MR. RYAN M SALDIVAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RYAN M SALDIVAR LMT

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2884 HIGHWAY 14
MADRID NM
87010
US

IV. Provider business mailing address

PO BOX 425
CERRILLOS NM
87010-0425
US

V. Phone/Fax

Practice location:
  • Phone: 505-489-0598
  • Fax:
Mailing address:
  • Phone: 505-489-0598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number225700000X - MASSAGE
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: