Healthcare Provider Details

I. General information

NPI: 1669835187
Provider Name (Legal Business Name): CAROL SUSAN GRIFFITH I P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 04/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 SABANA GRANDE AVE SE
RIO RANCHO NM
87124-1152
US

IV. Provider business mailing address

4701 HUNTINGTON DR NE
ALBUQUERQUE NM
87111-3040
US

V. Phone/Fax

Practice location:
  • Phone: 505-816-7534
  • Fax:
Mailing address:
  • Phone: 505-275-9174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0922
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: