Healthcare Provider Details

I. General information

NPI: 1346639770
Provider Name (Legal Business Name): ANTHONY GUSTAMANTES MOTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 UNSER BLVD SE STE 9
RIO RANCHO NM
87124-6370
US

IV. Provider business mailing address

6239 SIERRA NEVADA CIR NW
ALBUQUERQUE NM
87114
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-7733
  • Fax: 505-892-9341
Mailing address:
  • Phone: 505-573-8105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT4637
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: