Provider Demographics
NPI:1306069224
Name:PHYSICAL THERAPY & SPORTS MEDICINE OF NORTHERN NEW MEXICO, INC.
Entity type:Organization
Organization Name:PHYSICAL THERAPY & SPORTS MEDICINE OF NORTHERN NEW MEXICO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SID
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:505-334-9616
Mailing Address - Street 1:505 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-1975
Mailing Address - Country:US
Mailing Address - Phone:505-334-9616
Mailing Address - Fax:505-334-7343
Practice Address - Street 1:505 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-1975
Practice Address - Country:US
Practice Address - Phone:505-334-9616
Practice Address - Fax:505-334-7343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-0483225200000X
NM1082255A2300X
NM1025225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM300521156Medicare PIN