Healthcare Provider Details

I. General information

NPI: 1972038917
Provider Name (Legal Business Name): PA MEDICAL REHAB CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 LOUISIANA BLVD NE STE H
ALBUQUERQUE NM
87110-3565
US

IV. Provider business mailing address

2900 LOUISIANA BLVD NE SUITE H
ALBUQUERQUE NM
87110
US

V. Phone/Fax

Practice location:
  • Phone: 505-582-1780
  • Fax:
Mailing address:
  • Phone: 505-582-1780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ORELVIS LOPEZ CASTILLO
Title or Position: PRESIDENT
Credential:
Phone: 505-582-1780