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General NPI Number Information
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NPI Number | 1447268958
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Entity Type | Organization
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Legal Business Name | SOUTHWEST PHYSICAL & SPORTS THERAPY, LTD
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Dates
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Enumeration Date | 08/03/2006
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Last Update Date | 02/06/2012
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Provider Practice Location Address
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Address Line | 2513 RIDGE RUNNER RD
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City | LAS VEGAS
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State | NM
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Zip | 87701-4972
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Country | US
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Telephone | 505-425-1117
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Fax | 505-454-7810
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Provider Business Mailing Address
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Address Line | 2513 RIDGE RUNNER RD
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City | LAS VEGAS
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State | NM
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Zip | 87701-4972
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Country | US
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Telephone | 505-425-1117
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Fax | 505-454-7810
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | MS. CAROLYN STOKLOSA
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Credential | PT
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Telephone | 505-425-1117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 6614
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License Number State | NM
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