Basic Information
| Provider Information | |||||||||
| NPI: | 1649528951 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THRIVE WELLNESS AND REHAB, P.L.L.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 LIVINGSTON LOOP | ||||||||
| Address2: | STE B-1 | ||||||||
| City: | SANTA TERESA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880089747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755877061 | ||||||||
| FaxNumber: | 9154938264 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 LIVINGSTON LOOP | ||||||||
| Address2: | STE B-1 | ||||||||
| City: | SANTA TERESA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880089747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755877061 | ||||||||
| FaxNumber: | 9154938264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2012 | ||||||||
| LastUpdateDate: | 09/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | GONZALEZ | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5755877061 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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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 |
No ID Information.