Healthcare Provider Details

I. General information

NPI: 1932619137
Provider Name (Legal Business Name): MARCEL MILLADO MODELO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1692B HOSPITAL DR
SANTA FE NM
87505-4825
US

IV. Provider business mailing address

1692B HOSPITAL DR
SANTA FE NM
87505-4825
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-6399
  • Fax: 505-982-3219
Mailing address:
  • Phone: 505-982-6399
  • Fax: 505-982-3219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0777
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: