Healthcare Provider Details

I. General information

NPI: 1053118000
Provider Name (Legal Business Name): MAELENE SANDIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2025
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 QUANTUM RD NE
RIO RANCHO NM
87124-4505
US

IV. Provider business mailing address

1112 EDITH BLVD NE
ALBUQUERQUE NM
87102-2414
US

V. Phone/Fax

Practice location:
  • Phone: 505-908-1026
  • Fax:
Mailing address:
  • Phone: 505-908-1026
  • Fax: 505-908-1026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-2025-0019
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: