Healthcare Provider Details

I. General information

NPI: 1982777850
Provider Name (Legal Business Name): ESPANOLA SPORTS MEDICINE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 LA JOYA ST
ESPANOLA NM
87532-2511
US

IV. Provider business mailing address

708 LA JOYA ST
ESPANOLA NM
87532-2511
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-6550
  • Fax: 505-753-1219
Mailing address:
  • Phone: 505-753-6550
  • Fax: 505-753-1219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6628
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number6628
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: THERESA LYNN GODFREY
Title or Position: SENIOR ACCOUNTANT
Credential:
Phone: 402-334-1919