Provider Demographics
NPI:1568035582
Name:MORRIS, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:MORRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 69 BOX 66
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:NM
Mailing Address - Zip Code:88265-9704
Mailing Address - Country:US
Mailing Address - Phone:646-974-0035
Mailing Address - Fax:
Practice Address - Street 1:10395 REDFEARN RD
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:NM
Practice Address - Zip Code:88265-8826
Practice Address - Country:US
Practice Address - Phone:646-974-0035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM509241813172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver