Healthcare Provider Details

I. General information

NPI: 1285943787
Provider Name (Legal Business Name): NEW MEXICO PHYSICAL THERAPISTS DBA VIBRANTCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211C MAIN ST SE
LOS LUNAS NM
87031-8297
US

IV. Provider business mailing address

2270 DOUGLAS BLVD STE 112
ROSEVILLE CA
95661-4239
US

V. Phone/Fax

Practice location:
  • Phone: 505-866-1677
  • Fax: 505-866-1767
Mailing address:
  • Phone: 800-421-1965
  • Fax: 916-773-1481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number3896
License Number StateNM

VIII. Authorized Official

Name: JENNIFER NICHOLSON
Title or Position: HR
Credential:
Phone: 800-421-1965