Provider Demographics
NPI:1255778874
Name:SW MYOFUNCTIONAL THERAPY LLC
Entity type:Organization
Organization Name:SW MYOFUNCTIONAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MYOFUNCTIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SANDRALUZ
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:505-550-6042
Mailing Address - Street 1:5317 DON MIGUEL PL SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-5410
Mailing Address - Country:US
Mailing Address - Phone:505-550-6042
Mailing Address - Fax:
Practice Address - Street 1:5317 DON MIGUEL PL SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-5410
Practice Address - Country:US
Practice Address - Phone:505-550-6042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-23
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH12281124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty