Healthcare Provider Details

I. General information

NPI: 1922574334
Provider Name (Legal Business Name): BRIAN TERRY NM LMT 8964
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 SALAZAR ST # A
SANTA FE NM
87501-3642
US

IV. Provider business mailing address

530 SALAZAR ST # A
SANTA FE NM
87501-3642
US

V. Phone/Fax

Practice location:
  • Phone: 970-222-2710
  • Fax:
Mailing address:
  • Phone: 970-222-2710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8964
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: