Healthcare Provider Details

I. General information

NPI: 1295778470
Provider Name (Legal Business Name): JEMEZ PHYSICAL THERAPY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 TRINITY DR STE N
LOS ALAMOS NM
87544-4103
US

IV. Provider business mailing address

2101 TRINITY DR STE N
LOS ALAMOS NM
87544-4103
US

V. Phone/Fax

Practice location:
  • Phone: 505-661-6191
  • Fax: 505-663-0386
Mailing address:
  • Phone: 505-661-6191
  • Fax: 505-663-0386

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: LORRAINE L GARDNER
Title or Position: PRESIDENT
Credential: P.T.
Phone: 505-661-6191