MEDICARE: RUNFREEPT

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	261QP2000X	Physical Therapy Clinic/Center	4487	NM

General Provider Information

NPI Number	:	1851700058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUNFREEPT

Provider Business Mailing Address
First Line	:	20 MEADOW HAWK LN
Second Line	:
City	:	SILVER CITY
State	:	NM
Zip	:	88022-9727
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 MEADOW HAWK LN
Second Line	:
City	:	SILVER CITY
State	:	NM
Zip	:	88022-9727
Country	:	US
Telephone Number	:	541-951-8170
Fax Number	:

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	FREEBORN MONDELLO
Credential	:	DPT
Telephone Number	:	541-951-8170

Provider Enumeration Date	:	08/13/2014
Last Update Date	:	08/13/2014

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Directions to “RUNFREEPT ” Practice Location

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