Provider Demographics
NPI:1558626333
Name:MEYER, JUSTIN (LMT 6784)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:MEYER
Suffix:
Gender:M
Credentials:LMT 6784
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 EL PRADO DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015-9750
Mailing Address - Country:US
Mailing Address - Phone:505-720-0700
Mailing Address - Fax:
Practice Address - Street 1:3408 CONSTITUTION AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-1200
Practice Address - Country:US
Practice Address - Phone:505-720-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6784225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist