Provider Demographics
NPI:1366442865
Name:TURQUOISE TRAIL PHYSICAL THERAPY AND REHABILITATION
Entity Type:Organization
Organization Name:TURQUOISE TRAIL PHYSICAL THERAPY AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:HOERNING
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:505-984-2032
Mailing Address - Street 1:PO BOX 29269
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87592-9269
Mailing Address - Country:US
Mailing Address - Phone:505-984-2032
Mailing Address - Fax:505-984-0738
Practice Address - Street 1:786A N SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-5100
Practice Address - Country:US
Practice Address - Phone:505-984-2032
Practice Address - Fax:505-984-0738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6187261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN5084Medicaid
NM32-6533Medicare ID - Type Unspecified