Basic Information
| Provider Information | |||||||||
| NPI: | 1205934619 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TAOS PHYSICAL THERAPY, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6955 NDCBU | ||||||||
| Address2: | |||||||||
| City: | TAOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875716498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757588761 | ||||||||
| FaxNumber: | 5757510448 | ||||||||
| Practice Location | |||||||||
| Address1: | 414 SIPAPU STREET | ||||||||
| Address2: | |||||||||
| City: | TAOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875716498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757588761 | ||||||||
| FaxNumber: | 5757510448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ESPARZA | ||||||||
| AuthorizedOfficialFirstName: | ALICIA | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 5757588761 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | P.T. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | N5566 | 05 | NM | MEDICAID |