Healthcare Provider Details

I. General information

NPI: 1760958730
Provider Name (Legal Business Name): GAIN PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 AVENIDA CAMPO VERDE
SANTA FE NM
87506-0269
US

IV. Provider business mailing address

PO BOX 184
TESUQUE NM
87574-0184
US

V. Phone/Fax

Practice location:
  • Phone: 505-257-8288
  • Fax:
Mailing address:
  • Phone: 505-257-8288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. ERIC DOUGLAS PAYNE
Title or Position: OWNER
Credential: PT, DPT, OCS
Phone: 505-257-8288