Healthcare Provider Details

I. General information

NPI: 1326551961
Provider Name (Legal Business Name): TEVIN GRIFFIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2017
Last Update Date: 11/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E MIEL DE LUNA AVE
TUCUMCARI NM
88401-3810
US

IV. Provider business mailing address

3908 N 110TH PLZ
OMAHA NE
68164-2846
US

V. Phone/Fax

Practice location:
  • Phone: 575-461-7230
  • Fax:
Mailing address:
  • Phone: 402-452-7410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1598
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1459
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: