Healthcare Provider Details

I. General information

NPI: 1750751632
Provider Name (Legal Business Name): CIBOLA SPORTS AND PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 MOUNTAIN RD
GRANTS NM
87020-2602
US

IV. Provider business mailing address

242 MOUNTAIN RD
GRANTS NM
87020-2602
US

V. Phone/Fax

Practice location:
  • Phone: 505-876-6030
  • Fax: 505-876-6151
Mailing address:
  • Phone: 505-876-6030
  • Fax: 505-876-6151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAEL TODD ROHDE
Title or Position: PHYSICAL THERAPIST/OWNER
Credential: PT, ATC
Phone: 505-876-6030