Healthcare Provider Details

I. General information

NPI: 1649572348
Provider Name (Legal Business Name): ANTHONY L. ARVISO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 E HISTORIC HIGHWAY 66 SUITE 5
GALLUP NM
87301-4883
US

IV. Provider business mailing address

1900 E HISTORIC HIGHWAY 66 SUITE 5
GALLUP NM
87301-4883
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-4199
  • Fax: 505-863-4196
Mailing address:
  • Phone: 505-863-4199
  • Fax: 505-863-4196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2734
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2151
License Number StateNM

VIII. Authorized Official

Name: ANTHONY LIONEL ARVISO
Title or Position: OWNER
Credential: PT
Phone: 505-863-4199