Healthcare Provider Details

I. General information

NPI: 1265586622
Provider Name (Legal Business Name): MARY MILES LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 N CALIFORNIA ST SUITE # 7
SOCORRO NM
87801-5221
US

IV. Provider business mailing address

34 B MONTOYA RD. PO BOX 475
SAN ANTONIO NM
87832-0475
US

V. Phone/Fax

Practice location:
  • Phone: 505-740-2465
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3099
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: