Basic Information
| Provider Information | |||||||||
| NPI: | 1104357003 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOVELACE UNM REHABILITATION HOSPITAL LLC | ||||||||
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| OtherOrganizationName: | LOVELACE UNM OUTPATIENT REHABILITATION AT JEMEZ PUEBLO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BURTON HILLS BLVD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372156293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152963000 | ||||||||
| FaxNumber: | 6152966227 | ||||||||
| Practice Location | |||||||||
| Address1: | 129 A CANAL STREET | ||||||||
| Address2: | |||||||||
| City: | JEMEZ PUEBLO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5758349168 | ||||||||
| FaxNumber: | 5758340238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2017 | ||||||||
| LastUpdateDate: | 03/22/2017 | ||||||||
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| AuthorizedOfficialLastName: | PETROVICH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP | ||||||||
| AuthorizedOfficialTelephone: | 6152963000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ARDENTH HEALTH PARTNERS LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.