Healthcare Provider Details

I. General information

NPI: 1023757747
Provider Name (Legal Business Name): TRAILHEAD PELVIC & VISCERAL PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 07/17/2022
Certification Date: 07/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7013 4TH ST NW STE I
LOS RANCHOS DE ALBUQUERQUE NM
87107-6639
US

IV. Provider business mailing address

30 ANASAZI TRAILS LOOP
PLACITAS NM
87043-8760
US

V. Phone/Fax

Practice location:
  • Phone: 505-357-0055
  • Fax:
Mailing address:
  • Phone: 505-639-9937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. SUSANNA P VANDERWALT
Title or Position: CEO
Credential:
Phone: 505-639-9937