Provider Demographics
NPI:1750457834
Name:COLLINS, ROGER RONALD (AT, C, L A T)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:RONALD
Last Name:COLLINS
Suffix:
Gender:M
Credentials:AT, C, L A T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 SPOTTED WOLF AVE
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-2093
Mailing Address - Country:US
Mailing Address - Phone:505-334-5119
Mailing Address - Fax:
Practice Address - Street 1:604 S RIO GRANDE AVE
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-2260
Practice Address - Country:US
Practice Address - Phone:505-334-9616
Practice Address - Fax:505-334-7343
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer