Healthcare Provider Details

I. General information

NPI: 1114855491
Provider Name (Legal Business Name): TINA M VALLEJOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2026
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 HIGHWAY 60
SOCORRO NM
87801-3914
US

IV. Provider business mailing address

11623 ARBOR ST STE 200
OMAHA NE
68144-2991
US

V. Phone/Fax

Practice location:
  • Phone: 575-838-4690
  • Fax:
Mailing address:
  • Phone: 402-334-6014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPT-2026-0109
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: