Healthcare Provider Details

I. General information

NPI: 1710256300
Provider Name (Legal Business Name): JESSE T GARZA PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2011
Last Update Date: 12/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911B N CALIFORNIA ST
SOCORRO NM
87801-4269
US

IV. Provider business mailing address

911 B N CALIFORNIA ST
SOCORRO NM
87801
US

V. Phone/Fax

Practice location:
  • Phone: 575-838-1000
  • Fax: 575-838-2000
Mailing address:
  • Phone: 575-838-1000
  • Fax: 575-838-2000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0831
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: