Provider Demographics
NPI:1164573119
Name:TRIA, REUEL JOSEPH (PT)
Entity Type:Individual
Prefix:MR
First Name:REUEL
Middle Name:JOSEPH
Last Name:TRIA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N MISSOURI AVE APT 20
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-4860
Mailing Address - Country:US
Mailing Address - Phone:505-317-8559
Mailing Address - Fax:
Practice Address - Street 1:300 N KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4636
Practice Address - Country:US
Practice Address - Phone:505-625-2571
Practice Address - Fax:505-627-2544
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3236225100000X
VA2305211438225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM72021888Medicaid