Healthcare Provider Details

I. General information

NPI: 1912445214
Provider Name (Legal Business Name): VERNON VILLANUEVA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 BROADWAY ST APT 9
WILLIAMSBURG NM
87942
US

IV. Provider business mailing address

3530 FOOTHILLS RD STE N
LAS CRUCES NM
88011-3621
US

V. Phone/Fax

Practice location:
  • Phone: 210-544-4857
  • Fax:
Mailing address:
  • Phone: 575-532-6054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4949
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: