Healthcare Provider Details

I. General information

NPI: 1366847725
Provider Name (Legal Business Name): LIVING WATERS PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 RANCHERO RD
BOSQUE FARMS NM
87068-9123
US

IV. Provider business mailing address

955 RANCHERO RD
BOSQUE FARMS NM
87068-9123
US

V. Phone/Fax

Practice location:
  • Phone: 505-369-8447
  • Fax:
Mailing address:
  • Phone: 505-369-8447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number3824
License Number StateNM

VIII. Authorized Official

Name: JUDITH PATRICIA BARRETT
Title or Position: PHYSICAL THERAPIST/ OWNER
Credential: PT
Phone: 505-369-8447