Provider Demographics
NPI:1174780639
Name:DWIGGINS, DAMON (LMT)
Entity type:Individual
Prefix:
First Name:DAMON
Middle Name:
Last Name:DWIGGINS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 S TELSHOR BLVD
Mailing Address - Street 2:BLDG C SUITE 201
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4688
Mailing Address - Country:US
Mailing Address - Phone:575-640-2088
Mailing Address - Fax:575-522-3959
Practice Address - Street 1:755 S TELSHOR BLVD
Practice Address - Street 2:BLDG C SUITE 201
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4688
Practice Address - Country:US
Practice Address - Phone:575-640-2088
Practice Address - Fax:575-522-3959
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5765225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM539707-07OtherNATIONAL CERTIFICATION BOARD OF THERAPEUTIC MASSAGE
NM5765OtherNEW MEXICO MASSAGE THERAPY BOARD