=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306069224
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICAL THERAPY & SPORTS MEDICINE OF NORTHERN NEW MEXICO, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2007
-----------------------------------------------------
Last Update Date | 10/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 N MAIN AVE
-----------------------------------------------------
City | AZTEC
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87410-1942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-334-9616
-----------------------------------------------------
Fax | 505-334-7343
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 N MAIN AVE
-----------------------------------------------------
City | AZTEC
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87410-1942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-334-9616
-----------------------------------------------------
Fax | 505-334-7343
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | SID MOSIMAN
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 505-334-9616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 108
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | A-0483
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1025
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------