Provider Demographics
NPI:1265498471
Name:RUIDOSO PHYSICAL THERAPY CLINIC, INC
Entity Type:Organization
Organization Name:RUIDOSO PHYSICAL THERAPY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:RADOSEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:575-257-1800
Mailing Address - Street 1:439 MECHEM DR
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-6813
Mailing Address - Country:US
Mailing Address - Phone:575-257-1800
Mailing Address - Fax:575-257-2319
Practice Address - Street 1:439 MECHEM DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6813
Practice Address - Country:US
Practice Address - Phone:575-257-1800
Practice Address - Fax:575-257-2319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1781225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000L2933Medicaid
NM345530904Medicare PIN
NM348509902Medicare PIN
NML2933Medicaid