Healthcare Provider Details

I. General information

NPI: 1427130137
Provider Name (Legal Business Name): NEW MEXICO SPORTS & PT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 06/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2954 RODEO PARK DR W
SANTA FE NM
87505-6351
US

IV. Provider business mailing address

2954 RODEO PARK DR W
SANTA FE NM
87505-6351
US

V. Phone/Fax

Practice location:
  • Phone: 505-424-0131
  • Fax: 505-424-1299
Mailing address:
  • Phone: 505-424-0131
  • Fax: 505-424-1299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number6292
License Number StateNM

VIII. Authorized Official

Name: MR. THOMAS H FAGAN
Title or Position: PRESIDENT
Credential: P T
Phone: 505-424-0131