Provider Demographics
NPI:1477542041
Name:SUMMIT REHABILITATION LLC
Entity Type:Organization
Organization Name:SUMMIT REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/MANAGING PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:505-546-2555
Mailing Address - Street 1:722 E FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-5310
Mailing Address - Country:US
Mailing Address - Phone:505-546-2555
Mailing Address - Fax:505-546-2725
Practice Address - Street 1:722 E FLORIDA ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-5310
Practice Address - Country:US
Practice Address - Phone:505-546-2555
Practice Address - Fax:505-546-2725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2570225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
104461700OtherUS DEPT OF LABOR
73559OtherPRES
P00079902OtherRR MEDICARE
23693OtherLVLC
NM57831271Medicaid
NMO1Q136OtherBCBS
104461700OtherUS DEPT OF LABOR