Healthcare Provider Details

I. General information

NPI: 1801245774
Provider Name (Legal Business Name): HOT SPRINGS SPORTS & THERAPY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2016
Last Update Date: 06/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 SUPERIOR RD
ELEPHANT BUTTE NM
87935
US

IV. Provider business mailing address

PO BOX 3396
TRUTH OR CONSEQUENCES NM
87901-7396
US

V. Phone/Fax

Practice location:
  • Phone: 575-894-0485
  • Fax:
Mailing address:
  • Phone: 575-894-0485
  • Fax: 575-894-0495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3290
License Number StateNM

VIII. Authorized Official

Name: LESLIE DIANE BOONE
Title or Position: PHYSICAL THERAPY
Credential:
Phone: 575-894-0485