Provider Demographics
NPI:1689706590
Name:CORDOVA, DANIEL (OTRL)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:CORDOVA
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 BLUEBIRD RD.
Mailing Address - Street 2:
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043-8835
Mailing Address - Country:US
Mailing Address - Phone:505-980-0027
Mailing Address - Fax:505-867-1392
Practice Address - Street 1:20 BLUEBIRD RD.
Practice Address - Street 2:
Practice Address - City:PLACITAS
Practice Address - State:NM
Practice Address - Zip Code:87043-8835
Practice Address - Country:US
Practice Address - Phone:505-980-0027
Practice Address - Fax:505-867-1392
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1785174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist