Provider Demographics
NPI:1265586622
Name:MILES, MARY (LMT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 B MONTOYA RD.
Mailing Address - Street 2:PO BOX 475
Mailing Address - City:SAN ANTONIO
Mailing Address - State:NM
Mailing Address - Zip Code:87832-0475
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:722 N CALIFORNIA ST
Practice Address - Street 2:SUITE # 7
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-5221
Practice Address - Country:US
Practice Address - Phone:505-740-2465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3099225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist