Healthcare Provider Details

I. General information

NPI: 1891151643
Provider Name (Legal Business Name): PETER BRUZAS LAT, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2016
Last Update Date: 01/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 E COLLEGE BLVD
ROSWELL NM
88201-5158
US

IV. Provider business mailing address

3300 N ATKINSON AVE APT 15
ROSWELL NM
88201-7819
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-6500
  • Fax:
Mailing address:
  • Phone: 704-249-5685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number613
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: