Healthcare Provider Details

I. General information

NPI: 1194829614
Provider Name (Legal Business Name): WESTSIDE MYOFASCIAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 BARBARA LOOP SE SUITE 108
RIO RANCHO NM
87124-1039
US

IV. Provider business mailing address

4011 BARBARA LOOP SE SUITE 108
RIO RANCHO NM
87124-1039
US

V. Phone/Fax

Practice location:
  • Phone: 505-792-2592
  • Fax: 505-792-2814
Mailing address:
  • Phone: 505-792-2592
  • Fax: 505-792-2814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3940
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SHARI ANN DENTON
Title or Position: OWNER, THERAPIST
Credential: LMT, NMT, TPMT
Phone: 505-792-2592