Healthcare Provider Details

I. General information

NPI: 1417814617
Provider Name (Legal Business Name): SHERYL CLARK
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2026
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BARBARA LOOP SE STE C
RIO RANCHO NM
87124-1088
US

IV. Provider business mailing address

14305 CENTRAL AVE NW
ALBUQUERQUE NM
87121-7741
US

V. Phone/Fax

Practice location:
  • Phone: 505-750-0055
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0080
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: