Provider Demographics
NPI:1023757747
Name:TRAILHEAD PELVIC & VISCERAL PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:TRAILHEAD PELVIC & VISCERAL PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSANNA
Authorized Official - Middle Name:P
Authorized Official - Last Name:VANDERWALT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-639-9937
Mailing Address - Street 1:30 ANASAZI TRAILS LOOP
Mailing Address - Street 2:
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043-8760
Mailing Address - Country:US
Mailing Address - Phone:505-639-9937
Mailing Address - Fax:
Practice Address - Street 1:7013 4TH ST NW STE I
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS DE ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-6639
Practice Address - Country:US
Practice Address - Phone:505-357-0055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-01
Last Update Date:2022-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty