MEDICARE: MR. DALE GLEN BAGLEY PT

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

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	00NM00Q089	OTHER	NM	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1568470995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DALE GLEN BAGLEY PT

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	07/24/2008

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