Healthcare Provider Details

I. General information

NPI: 1568035582
Provider Name (Legal Business Name): TIMOTHY MORRIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 07/19/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10395 REDFEARN RD
MONUMENT NM
88265-8826
US

IV. Provider business mailing address

HC 69 BOX 66
MONUMENT NM
88265-9704
US

V. Phone/Fax

Practice location:
  • Phone: 646-974-0035
  • Fax:
Mailing address:
  • Phone: 646-974-0035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number509241813
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: