Provider Demographics
NPI:1124195540
Name:MILAGRO THERAPY SERVICES LLC
Entity Type:Organization
Organization Name:MILAGRO THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BONILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:505-699-1097
Mailing Address - Street 1:PO BOX 253
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-0253
Mailing Address - Country:US
Mailing Address - Phone:505-699-0512
Mailing Address - Fax:505-454-9565
Practice Address - Street 1:220 PLAZA ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-3433
Practice Address - Country:US
Practice Address - Phone:505-699-1097
Practice Address - Fax:505-454-9565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3205225100000X
NM2181225X00000X
NM2133235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM16073029Medicaid