Healthcare Provider Details

I. General information

NPI: 1669015350
Provider Name (Legal Business Name): SPRING BEAVERS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2019
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 CALLE MEDICO
SANTA FE NM
87505-4724
US

IV. Provider business mailing address

3005 S ST FRANCIS DR. #461 STE 1-D
SANTA FE NM
87505
US

V. Phone/Fax

Practice location:
  • Phone: 505-424-8777
  • Fax:
Mailing address:
  • Phone: 505-977-7331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1471
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: