Basic Information
| Provider Information | |||||||||
| NPI: | 1982777850 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ESPANOLA SPORTS MEDICINE, PA | ||||||||
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| OtherOrganizationName: | ESPANOLA SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 708 LA JOYA ST | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875322511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057536550 | ||||||||
| FaxNumber: | 5057531219 | ||||||||
| Practice Location | |||||||||
| Address1: | 708 LA JOYA ST | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875322511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057536550 | ||||||||
| FaxNumber: | 5057531219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 03/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | GODFREY | ||||||||
| AuthorizedOfficialFirstName: | THERESA | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR ACCOUNTANT | ||||||||
| AuthorizedOfficialTelephone: | 4023341919 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6628 | NM | N | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 261QP2000X | 6628 | NM | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | R5803 | 05 | NM | MEDICAID |