Provider Demographics
NPI:1346724689
Name:ANDERSON, GREG (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 BUFFALO CIR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-3524
Mailing Address - Country:US
Mailing Address - Phone:505-489-3903
Mailing Address - Fax:
Practice Address - Street 1:6855 4TH ST NW STE B-2
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-6100
Practice Address - Country:US
Practice Address - Phone:505-508-2752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-22
Last Update Date:2018-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMS-0553225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist