Provider Demographics
NPI:1396124517
Name:SANTA FE SPORTS MEDICINE AND REHAB
Entity type:Organization
Organization Name:SANTA FE SPORTS MEDICINE AND REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:KENYON
Authorized Official - Suffix:
Authorized Official - Credentials:MS,PT
Authorized Official - Phone:505-992-4995
Mailing Address - Street 1:104 OLD LAS VEGAS HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:505-992-4995
Mailing Address - Fax:505-992-4985
Practice Address - Street 1:104 OLD LAS VEGAS HWY
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-992-4995
Practice Address - Fax:505-992-4985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4090261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy