Healthcare Provider Details

I. General information

NPI: 1770173544
Provider Name (Legal Business Name): BOSQUE PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 01/25/2021
Certification Date: 01/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 HWY 346
BOSQUE NM
87006
US

IV. Provider business mailing address

PO BOX 460
BOSQUE NM
87006-0460
US

V. Phone/Fax

Practice location:
  • Phone: 505-450-3451
  • Fax:
Mailing address:
  • Phone: 505-450-3451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: VALERIE GUTIERREZ
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: DPT
Phone: 505-450-3451