Provider Demographics
NPI:1346276508
Name:SOUTHWEST ORTHOPAEDIC PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:SOUTHWEST ORTHOPAEDIC PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER LLC/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KALE
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:ISAACSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-292-3317
Mailing Address - Street 1:1334 WYOMING BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-5067
Mailing Address - Country:US
Mailing Address - Phone:505-292-3317
Mailing Address - Fax:505-292-3402
Practice Address - Street 1:1334 WYOMING BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-5067
Practice Address - Country:US
Practice Address - Phone:505-292-3317
Practice Address - Fax:505-292-3402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM07726333Medicaid
900521034Medicare PIN