Healthcare Provider Details

I. General information

NPI: 1396908653
Provider Name (Legal Business Name): SPINE & MUSCLE REHABILITATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 09/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 ACADEMY RD NE SUITE #340
ALBUQUERQUE NM
87111-7372
US

IV. Provider business mailing address

POB 20057
ALBUQUERQUE NM
87154
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-1558
  • Fax: 505-298-7012
Mailing address:
  • Phone: 505-298-1558
  • Fax: 505-298-7012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberR38331
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberR35692
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number5499
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number6070
License Number StateNM
# 5
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number4933
License Number StateNM

VIII. Authorized Official

Name: KENNETH G. ABBOTT
Title or Position: VICE PRESIDENT
Credential:
Phone: 505-298-1558