Healthcare Provider Details

I. General information

NPI: 1164038204
Provider Name (Legal Business Name): ROCK PHYSICAL THERAPY RESILIENCE & TRAINING CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 01/04/2021
Certification Date: 01/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 SULLIVAN AVE
FARMINGTON NM
87401-7356
US

IV. Provider business mailing address

845 N SULLIVAN AVE
FARMINGTON NM
87401-7356
US

V. Phone/Fax

Practice location:
  • Phone: 505-860-7812
  • Fax:
Mailing address:
  • Phone: 505-278-8295
  • Fax: 505-436-2077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MARLYN BRIAN WYATT
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: DPT
Phone: 505-278-8295