Provider Demographics
NPI:1467634469
Name:FOWLER ENTERPRISES INC.
Entity Type:Organization
Organization Name:FOWLER ENTERPRISES INC.
Other - Org Name:EAST MOUNTAIN PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:W
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:505-220-6949
Mailing Address - Street 1:PO BOX 1730
Mailing Address - Street 2:
Mailing Address - City:MORIARTY
Mailing Address - State:NM
Mailing Address - Zip Code:87035-1730
Mailing Address - Country:US
Mailing Address - Phone:505-832-4011
Mailing Address - Fax:
Practice Address - Street 1:12127 B3 N. HWY 14
Practice Address - Street 2:
Practice Address - City:CEDAR CREST
Practice Address - State:NM
Practice Address - Zip Code:87008
Practice Address - Country:US
Practice Address - Phone:505-286-3678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM08028079Medicaid
NM08028079Medicaid