Provider Demographics
NPI:1427323633
Name:ZAVALA, JUAN CARLOS (MASSAGE THERAPIST)
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:CARLOS
Last Name:ZAVALA
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:MR
Other - First Name:JUAN
Other - Middle Name:CARLOS
Other - Last Name:ZAVALA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MASSAGE THERAPIST
Mailing Address - Street 1:230 ADAMS STREET
Mailing Address - Street 2:S.E.
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108
Mailing Address - Country:US
Mailing Address - Phone:505-843-7492
Mailing Address - Fax:
Practice Address - Street 1:230 ADAMS ST SE
Practice Address - Street 2:S.E.
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2805
Practice Address - Country:US
Practice Address - Phone:505-843-7492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLMT 3032171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor