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General NPI Number Information
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NPI Number | 1679860175
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Entity Type | Organization
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Legal Business Name | PATIENCE GRASSHOPPER THERAPEUTICS
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Dates
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Enumeration Date | 07/05/2011
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Last Update Date | 07/05/2011
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Provider Practice Location Address
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Address Line | 16306 B HWY 84
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City | CHAMA
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State | NM
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Zip | 87520
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Country | US
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Telephone | 575-756-8391
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 301
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City | CHAMA
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State | NM
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Zip | 87520-0301
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Country | US
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Telephone | 575-756-8391
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Fax |
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Authorized Official
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Title or Position | OWNER, PROVIDER
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Name | AMILIA ANNE ELLIOTT
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Credential | M.P.T.
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Telephone | 575-756-8391
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 2983
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License Number State | NM
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