Healthcare Provider Details

I. General information

NPI: 1497818850
Provider Name (Legal Business Name): MARK W MENARD PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 SAINT MICHAELS DR
SANTA FE NM
87505-7672
US

IV. Provider business mailing address

63 BROWN CASTLE RNCH
SANTA FE NM
87508-1302
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-8860
  • Fax: 505-989-7204
Mailing address:
  • Phone: 505-471-0307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1076
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: