Provider Demographics
NPI:1891209987
Name:BALVERDE, MARK ALEXIS (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALEXIS
Last Name:BALVERDE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 HILLRISE CIR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4759
Mailing Address - Country:US
Mailing Address - Phone:575-522-9500
Mailing Address - Fax:
Practice Address - Street 1:1350 HILLRISE CIR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4759
Practice Address - Country:US
Practice Address - Phone:575-522-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-28
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11240208100000X
NM5157225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB416-541-88-443-0OtherDRIVER'S LICENSE NUMBER