Provider Demographics
NPI:1649572348
Name:ANTHONY L. ARVISO
Entity Type:Organization
Organization Name:ANTHONY L. ARVISO
Other - Org Name:ENCHANTMENT PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:LIONEL
Authorized Official - Last Name:ARVISO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:505-863-4199
Mailing Address - Street 1:1900 E HISTORIC HIGHWAY 66
Mailing Address - Street 2:SUITE 5
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4883
Mailing Address - Country:US
Mailing Address - Phone:505-863-4199
Mailing Address - Fax:505-863-4196
Practice Address - Street 1:1900 E HISTORIC HIGHWAY 66
Practice Address - Street 2:SUITE 5
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4883
Practice Address - Country:US
Practice Address - Phone:505-863-4199
Practice Address - Fax:505-863-4196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2151261QP2000X
NM2734261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ313193OtherAHCCCS
NM58607269Medicaid