Healthcare Provider Details

I. General information

NPI: 1992188403
Provider Name (Legal Business Name): GERIATRIC PM&R LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 VISTA DEL REY DR
EL PASO TX
79912-4824
US

IV. Provider business mailing address

PO BOX 700390, DEPT 0471
TULSA OK
74170-0390
US

V. Phone/Fax

Practice location:
  • Phone: 915-209-0157
  • Fax:
Mailing address:
  • Phone: 254-727-9193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: CATHERINE WAKEHAM
Title or Position: OWNER
Credential: MD
Phone: 915-209-0589