Healthcare Provider Details

I. General information

NPI: 1104601046
Provider Name (Legal Business Name): BREANNA GARVIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2023
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 21ST ST SE STE 9
RIO RANCHO NM
87124-4030
US

IV. Provider business mailing address

8001 TUSCARORA RD NW
ALBUQUERQUE NM
87114-5901
US

V. Phone/Fax

Practice location:
  • Phone: 505-985-6359
  • Fax:
Mailing address:
  • Phone: 505-985-6359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: