Healthcare Provider Details

I. General information

NPI: 1649524117
Provider Name (Legal Business Name): CUATITAS PHYSICAL & SPORTS THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2503 RIDGE RUNNER RD
LAS VEGAS NM
87701-4972
US

IV. Provider business mailing address

519 VEGAS DR
LAS VEGAS NM
87701-4690
US

V. Phone/Fax

Practice location:
  • Phone: 505-454-1078
  • Fax: 505-454-1164
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3441
License Number StateNM

VIII. Authorized Official

Name: MARIO J LUCERO
Title or Position: MANAGER/OWNER
Credential:
Phone: 505-715-3451