MEDICARE: SOUTHWEST PHYSICAL & SPORTS THERAPY, LTD

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	6614	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	201079769	OTHER	NM	PRESBYTERIAN HEALTH

General Provider Information

NPI Number	:	1447268958
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST PHYSICAL & SPORTS THERAPY, LTD

Provider Business Mailing Address
First Line	:	2513 RIDGE RUNNER RD
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4972
Country	:	US
Telephone Number	:	505-425-1117
Fax Number	:	505-454-7810

Provider Business Practice Location Address
First Line	:	2513 RIDGE RUNNER RD
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4972
Country	:	US
Telephone Number	:	505-425-1117
Fax Number	:	505-454-7810

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MS. CAROLYN STOKLOSA
Credential	:	PT
Telephone Number	:	505-425-1117

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	02/06/2012

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