Provider Demographics
NPI:1851700058
Name:RUNFREEPT
Entity Type:Organization
Organization Name:RUNFREEPT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:FREEBORN
Authorized Official - Middle Name:
Authorized Official - Last Name:MONDELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:541-951-8170
Mailing Address - Street 1:20 MEADOW HAWK LN
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88022-9727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 MEADOW HAWK LN
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88022-9727
Practice Address - Country:US
Practice Address - Phone:541-951-8170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4487261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy