Healthcare Provider Details

I. General information

NPI: 1124321450
Provider Name (Legal Business Name): KOMALA THERAPEUTIC MASSAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 RIO RANCHO BLVD SUITE 6G
RIO RANCHO NM
87124
US

IV. Provider business mailing address

1117 RIO RANCHO BLVD SUITE 6G
RIO RANCHO NM
87124
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-1414
  • Fax: 505-891-1444
Mailing address:
  • Phone: 505-891-1414
  • Fax: 505-891-1444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number10-00011070
License Number StateNM

VIII. Authorized Official

Name: MRS. SARAH E KOMALA
Title or Position: OWNER
Credential:
Phone: 505-891-1414