Basic Information
| Provider Information | |||||||||
| NPI: | 1700879590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TORY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2860 | ||||||||
| Address2: | |||||||||
| City: | ALAMOGORDO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 883112860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756280503 | ||||||||
| FaxNumber: | 5756283073 | ||||||||
| Practice Location | |||||||||
| Address1: | 128 S CANYON ST | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882205733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756280503 | ||||||||
| FaxNumber: | 5756283073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 06/09/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2617 | NM | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | NM00Q019 | 01 | NM | BLUE CROSS BLUE SHIELD | OTHER | 65579844 | 05 | NM | MEDICAID |