Provider Demographics
NPI:1053729236
Name:REFORM
Entity type:Organization
Organization Name:REFORM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:505-639-1400
Mailing Address - Street 1:10917 CARTAGENA AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-8274
Mailing Address - Country:US
Mailing Address - Phone:505-639-1400
Mailing Address - Fax:
Practice Address - Street 1:10917 CARTAGENA AVE SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-8274
Practice Address - Country:US
Practice Address - Phone:505-639-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit