Provider Demographics
NPI:1528380474
Name:PITTORE, ETTORE (PT)
Entity Type:Individual
Prefix:MR
First Name:ETTORE
Middle Name:
Last Name:PITTORE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CAPITAN ST NW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-6924
Mailing Address - Country:US
Mailing Address - Phone:304-963-0324
Mailing Address - Fax:
Practice Address - Street 1:2195 BOSQUE FARMS BLVD
Practice Address - Street 2:
Practice Address - City:BOSQUE FARMS
Practice Address - State:NM
Practice Address - Zip Code:87068-8941
Practice Address - Country:US
Practice Address - Phone:505-916-0213
Practice Address - Fax:505-916-5063
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV970225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPT5194OtherNM BOARD OF PHYSICAL THERAPY