Basic Information
| Provider Information | |||||||||
| NPI: | 1033124490 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARTESIA PHYSICAL THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2860 | ||||||||
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| City: | ALAMOGORDO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 883112860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754391397 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 W MAHONE DR | ||||||||
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| City: | ARTESIA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882102080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754391397 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 03/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | PATTILLO | ||||||||
| AuthorizedOfficialFirstName: | MELYNN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5754391397 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 02357 | 01 | NM | LOVELACE | OTHER | Q1865 | 05 | NM | MEDICAID | 26778 | 01 | NM | PRESBYTERIAN | OTHER |