Healthcare Provider Details

I. General information

NPI: 1710510458
Provider Name (Legal Business Name): ELLEN ANNETTE SANTISTEVAN-SALAZAR LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 SUNSET RD SE
RIO RANCHO NM
87124-2629
US

IV. Provider business mailing address

1410 SUNSET RD SE
RIO RANCHO NM
87124-2629
US

V. Phone/Fax

Practice location:
  • Phone: 505-363-5331
  • Fax:
Mailing address:
  • Phone: 505-363-5331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number5121
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: