Healthcare Provider Details

I. General information

NPI: 1902145543
Provider Name (Legal Business Name): MARY CLAIRE CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2013
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 RIO RANCHO BLVD SE
RIO RANCHO NM
87124-7020
US

IV. Provider business mailing address

1515 EUBANK BLVD SE BLDG. 831/832
ALBUQUERQUE NM
87123-3453
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-4950
  • Fax:
Mailing address:
  • Phone: 505-844-4237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT4934
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: