Healthcare Provider Details

I. General information

NPI: 1134299555
Provider Name (Legal Business Name): SOUTHWEST THERAPY & REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 21ST ST SE SUITE #9
RIO RANCHO NM
87124-4030
US

IV. Provider business mailing address

10900 TANZANITE DR NW
ALBUQUERQUE NM
87114-1853
US

V. Phone/Fax

Practice location:
  • Phone: 505-239-9644
  • Fax: 505-896-2958
Mailing address:
  • Phone: 505-239-9644
  • Fax: 505-896-2958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1435
License Number StateNM

VIII. Authorized Official

Name: MS. STAR AMBER RIDSDALE
Title or Position: OWNER
Credential: LMT
Phone: 505-239-9644