Provider Demographics
NPI:1346622651
Name:SPINE & MUSCLE REHABILITATION
Entity Type:Organization
Organization Name:SPINE & MUSCLE REHABILITATION
Other - Org Name:RAINBOW'S LEGACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:RAQUEL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:EMANUEL
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, RMTI, CNMT
Authorized Official - Phone:575-525-9960
Mailing Address - Street 1:1605 EL PASEO RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-6010
Mailing Address - Country:US
Mailing Address - Phone:575-525-9960
Mailing Address - Fax:575-525-9958
Practice Address - Street 1:1605 EL PASEO RD
Practice Address - Street 2:SUITE C
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-6010
Practice Address - Country:US
Practice Address - Phone:575-525-9960
Practice Address - Fax:575-525-9958
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPINE & MUSCLE REHAB
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5603302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM212488172Medicaid