Provider Demographics
NPI:1679725667
Name:SOUTHWEST MYOTHERAPY
Entity Type:Organization
Organization Name:SOUTHWEST MYOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:P
Authorized Official - Last Name:CARBONNEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-830-3585
Mailing Address - Street 1:4103 MONTGOMERY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1102
Mailing Address - Country:US
Mailing Address - Phone:505-830-3585
Mailing Address - Fax:505-830-3584
Practice Address - Street 1:4103 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1102
Practice Address - Country:US
Practice Address - Phone:505-830-3585
Practice Address - Fax:505-830-3584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1707225700000X
NM4024225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1114193893OtherNPI
NM1972650224OtherNPI