Provider Demographics
NPI:1689137754
Name:LA PLATA PHYSICAL MEDICINE PC
Entity Type:Organization
Organization Name:LA PLATA PHYSICAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:WALLACH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:970-403-3324
Mailing Address - Street 1:555 RIVERGATE STE B1-102
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7470
Mailing Address - Country:US
Mailing Address - Phone:970-403-3324
Mailing Address - Fax:970-232-2075
Practice Address - Street 1:555 RIVERGATE STE B1-102
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7470
Practice Address - Country:US
Practice Address - Phone:970-403-3324
Practice Address - Fax:970-232-2075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-07
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty