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General NPI Number Information
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NPI Number | 1982777850
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Entity Type | Organization
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Legal Business Name | ESPANOLA SPORTS MEDICINE, PA
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Dates
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Enumeration Date | 11/16/2006
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Last Update Date | 10/31/2023
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Provider Practice Location Address
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Address Line | 708 LA JOYA ST
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City | ESPANOLA
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State | NM
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Zip | 87532-2511
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Country | US
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Telephone | 505-753-6550
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Fax | 505-753-1219
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Provider Business Mailing Address
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Address Line | 708 LA JOYA ST
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City | ESPANOLA
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State | NM
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Zip | 87532-2511
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Country | US
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Telephone | 505-753-6550
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Fax | 505-753-1219
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Authorized Official
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Title or Position | SENIOR ACCOUNTANT
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Name | THERESA LYNN GODFREY
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Credential |
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Telephone | 402-334-1919
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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 | 6628
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 6628
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number |
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License Number State |
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