Healthcare Provider Details

I. General information

NPI: 1265026363
Provider Name (Legal Business Name): EVAN PICHE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 LOS REYES RD SE
RIO RANCHO NM
87124-1226
US

IV. Provider business mailing address

4400 LOS REYES RD SE
RIO RANCHO NM
87124-1226
US

V. Phone/Fax

Practice location:
  • Phone: 201-403-4231
  • Fax:
Mailing address:
  • Phone: 201-403-4231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5424
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: