Individual
DANE PERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
310 CONTINENTAL DRIVE, JAL, NM 88252
(575) 395-3400
(575) 395-3355
Mailing address
2991 ECLECTIC CT, WATKINS, CO 80137-7117
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
9366
NC
225100000X
Physical Therapist
Primary
PT5374
NM
Other
Enumeration date
05/03/2007
Last updated
02/28/2024
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