MEDICARE: PHYSICAL THERAPY CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	4234	NM
2	261QP2000X	Physical Therapy Clinic/Center	4234	NM

General Provider Information

NPI Number	:	1174867915
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICAL THERAPY CENTER, LLC

Provider Business Mailing Address
First Line	:	PO BOX 2694
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-2694
Country	:	US
Telephone Number	:	505-454-1213
Fax Number	:	505-425-2798

Provider Business Practice Location Address
First Line	:	1607 7TH ST STE C
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4952
Country	:	US
Telephone Number	:	505-454-1213
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LOGAN ARDEN KANODE
Credential	:	DPT
Telephone Number	:	505-454-1213

Provider Enumeration Date	:	11/17/2012
Last Update Date	:	06/18/2014

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