Provider Demographics
NPI:1942907811
Name:CALLEJO, ARCHELLE JANE CAPUNDAG
Entity Type:Individual
Prefix:
First Name:ARCHELLE JANE
Middle Name:CAPUNDAG
Last Name:CALLEJO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ARCHELLE JANE
Other - Middle Name:
Other - Last Name:CALLEJO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:925 LA DUE AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-3242
Mailing Address - Country:US
Mailing Address - Phone:321-960-0834
Mailing Address - Fax:
Practice Address - Street 1:177 CRAFT DR
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2248
Practice Address - Country:US
Practice Address - Phone:719-589-6425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0018675225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO172190848OtherDRIVERS LICENCE