Provider Demographics
NPI:1295778470
Name:JEMEZ PHYSICAL THERAPY, PC
Entity type:Organization
Organization Name:JEMEZ PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:505-661-6191
Mailing Address - Street 1:2101 TRINITY DR
Mailing Address - Street 2:STE N
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-4103
Mailing Address - Country:US
Mailing Address - Phone:505-661-6191
Mailing Address - Fax:505-663-0386
Practice Address - Street 1:2101 TRINITY DR
Practice Address - Street 2:STE N
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-4103
Practice Address - Country:US
Practice Address - Phone:505-661-6191
Practice Address - Fax:505-663-0386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPROVP12945OtherMOLINA
NMNM000NA25OtherBCBS OF NM
NM00074159Medicaid