Healthcare Provider Details

I. General information

NPI: 1801283452
Provider Name (Legal Business Name): MOVEMENT AND PERFORMANCE OF NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1612 RIDGECREST DR SE
ALBUQUERQUE NM
87108-4437
US

IV. Provider business mailing address

1612 RIDGECREST DR SE
ALBUQUERQUE NM
87108-4437
US

V. Phone/Fax

Practice location:
  • Phone: 505-250-7049
  • Fax:
Mailing address:
  • Phone: 505-250-7049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number3533
License Number StateNM

VIII. Authorized Official

Name: STEPHANIE L BACA
Title or Position: PHYSICAL THERAPIST/OWNER
Credential: PT
Phone: 505-250-7049