Provider Demographics
NPI:1316218910
Name:PHYSICAL THERAPY AND REHABILITATION SERVICES OF LAS CRUCES, LLC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY AND REHABILITATION SERVICES OF LAS CRUCES, LLC
Other - Org Name:PHYSICAL THERAPY AND REHABILITATION SERVICES OF LAS CRUCES, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:AVA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BORDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-522-0484
Mailing Address - Street 1:4151 CAMINO COYOTE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-7096
Mailing Address - Country:US
Mailing Address - Phone:575-522-0484
Mailing Address - Fax:575-522-0483
Practice Address - Street 1:4151 CAMINO COYOTE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-7096
Practice Address - Country:US
Practice Address - Phone:575-522-0484
Practice Address - Fax:575-522-0483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-13
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1564261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMA103004Medicare PIN