MEDICARE: PRIORITY PHYSICAL THERAPY NM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1881262749
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIORITY PHYSICAL THERAPY NM

Provider Business Mailing Address
First Line	:	1005 DON JUAN ST
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87501-2411
Country	:	US
Telephone Number	:	505-412-1463
Fax Number	:

Provider Business Practice Location Address
First Line	:	1005 DON JUAN ST
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87501-2411
Country	:	US
Telephone Number	:	505-412-1463
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. THOMAS F SANDOVAL
Credential	:	DPT
Telephone Number	:	505-412-1463

Provider Enumeration Date	:	06/16/2021
Last Update Date	:	06/16/2021

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