Provider Demographics
NPI:1316977085
Name:ADVANCED REHABILITATION SERVICE
Entity type:Organization
Organization Name:ADVANCED REHABILITATION SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:THIESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-299-2521
Mailing Address - Street 1:4001 JUAN TABO PLACE NE SUITE B
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQNE
Mailing Address - State:NM
Mailing Address - Zip Code:87111
Mailing Address - Country:US
Mailing Address - Phone:505-299-2521
Mailing Address - Fax:505-298-8899
Practice Address - Street 1:4001 JUAN TABO BLVD NE STE B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3979
Practice Address - Country:US
Practice Address - Phone:505-299-2521
Practice Address - Fax:505-298-8899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMIT3229261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM31536859Medicaid
NM31536859Medicaid