Healthcare Provider Details

I. General information

NPI: 1588973077
Provider Name (Legal Business Name): SW BRIAN INTEGRATION THERAPY & REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 21 ST. SE SUITE # 4
RIO RANCHO NM
87124
US

IV. Provider business mailing address

10900 TANZANITE DR NW
ALBUQUERQUE NM
87114-1853
US

V. Phone/Fax

Practice location:
  • Phone: 505-239-9644
  • Fax: 505-896-2958
Mailing address:
  • Phone: 505-239-2958
  • Fax: 505-896-2958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: STAR AMBER RIDSDALE
Title or Position: OWNER
Credential:
Phone: 505-239-9644