Provider Demographics
NPI:1467960336
Name:BLACKTHORNE, RHYDIAN (LMT)
Entity Type:Individual
Prefix:
First Name:RHYDIAN
Middle Name:
Last Name:BLACKTHORNE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 DOUGLAS MACARTHUR RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5138
Mailing Address - Country:US
Mailing Address - Phone:505-977-0666
Mailing Address - Fax:
Practice Address - Street 1:4010 CARLISLE BLVD NE STE D
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4532
Practice Address - Country:US
Practice Address - Phone:505-977-0666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-13
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171026225700000X
NMMT8347225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist