Provider Demographics
NPI:1598213852
Name:WILD ROSE HAND THERAPY LLC
Entity Type:Organization
Organization Name:WILD ROSE HAND THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FORNO
Authorized Official - Suffix:
Authorized Official - Credentials:MOTR/L
Authorized Official - Phone:970-779-0223
Mailing Address - Street 1:762 CAMINO FRANCISCA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506-6000
Mailing Address - Country:US
Mailing Address - Phone:970-779-0223
Mailing Address - Fax:
Practice Address - Street 1:1348 PACHECO ST
Practice Address - Street 2:UNIT 104
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4222
Practice Address - Country:US
Practice Address - Phone:970-779-0223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Single Specialty