Healthcare Provider Details

I. General information

NPI: 1902891989
Provider Name (Legal Business Name): JOSE O BARRON JR. ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W COLLEGE BLVD
ROSWELL NM
88201-5174
US

IV. Provider business mailing address

3011 FUTURA DR.
ROSWELL NM
88201
US

V. Phone/Fax

Practice location:
  • Phone: 575-624-8458
  • Fax: 575-624-8287
Mailing address:
  • Phone: 575-624-8458
  • Fax: 575-624-8446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number114
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: