Healthcare Provider Details

I. General information

NPI: 1992198741
Provider Name (Legal Business Name): SPACE FOR HEALING PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2015
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 LUISA ST SUITE 21
SANTA FE NM
87505-4204
US

IV. Provider business mailing address

PO BOX O
SANTA FE NM
87504-0558
US

V. Phone/Fax

Practice location:
  • Phone: 609-915-8047
  • Fax:
Mailing address:
  • Phone: 609-915-8047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number4157
License Number StateNM

VIII. Authorized Official

Name: FRANCES ERTEL
Title or Position: OWNER/DIRECTOR
Credential: PT
Phone: 609-915-8047