Basic Information
| Provider Information | |||||||||
| NPI: | 1841205200 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARLSBAD PHYSICAL THERAPY & WELLNESS CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2860 | ||||||||
| Address2: | |||||||||
| City: | ALAMOGORDO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 883112860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754391397 | ||||||||
| FaxNumber: | 5754372622 | ||||||||
| Practice Location | |||||||||
| Address1: | 126 S CANYON ST | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882205733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754391397 | ||||||||
| FaxNumber: | 5754372622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 04/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | PATTILLO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, ADMINISTRATIVE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5754391397 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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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 | E6877 | 05 | NM | MEDICAID |