Provider Demographics
NPI:1790213452
Name:FOUR13 THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:FOUR13 THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:AURAND-ANDES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-314-6116
Mailing Address - Street 1:24 FRANCES RD
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-5762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:505-214-5016
Practice Address - Street 1:24 FRANCES RD
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-5762
Practice Address - Country:US
Practice Address - Phone:505-314-6116
Practice Address - Fax:505-214-5016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3327225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1194116244Medicaid