Provider Demographics
NPI:1013049287
Name:GORES, MARGARET IRENE (PT)
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:IRENE
Last Name:GORES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 EASTLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4937
Mailing Address - Country:US
Mailing Address - Phone:970-749-4936
Mailing Address - Fax:
Practice Address - Street 1:505 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-1975
Practice Address - Country:US
Practice Address - Phone:505-334-9616
Practice Address - Fax:505-334-7343
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CO29052251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4232356Medicaid