Healthcare Provider Details

I. General information

NPI: 1851700058
Provider Name (Legal Business Name): RUNFREEPT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MEADOW HAWK LN
SILVER CITY NM
88022-9727
US

IV. Provider business mailing address

20 MEADOW HAWK LN
SILVER CITY NM
88022-9727
US

V. Phone/Fax

Practice location:
  • Phone: 541-951-8170
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number4487
License Number StateNM

VIII. Authorized Official

Name: FREEBORN MONDELLO
Title or Position: PHYSICAL THERAPIST
Credential: DPT
Phone: 541-951-8170