Healthcare Provider Details

I. General information

NPI: 1285763086
Provider Name (Legal Business Name): TARA J. FOULKE PHYSICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 W QUAY AVE
ARTESIA NM
88210-1826
US

IV. Provider business mailing address

1106 W QUAY AVE
ARTESIA NM
88210-1826
US

V. Phone/Fax

Practice location:
  • Phone: 505-746-2777
  • Fax:
Mailing address:
  • Phone: 505-746-2777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number93009569
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: