Healthcare Provider Details

I. General information

NPI: 1306069224
Provider Name (Legal Business Name): PHYSICAL THERAPY & SPORTS MEDICINE OF NORTHERN NEW MEXICO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 N MAIN AVE
AZTEC NM
87410-1942
US

IV. Provider business mailing address

505 N MAIN AVE
AZTEC NM
87410-1942
US

V. Phone/Fax

Practice location:
  • Phone: 505-334-9616
  • Fax: 505-334-7343
Mailing address:
  • Phone: 505-334-9616
  • Fax: 505-334-7343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number108
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0483
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1025
License Number StateNM

VIII. Authorized Official

Name: SID MOSIMAN
Title or Position: DIRECTOR
Credential: PT
Phone: 505-334-9616