Provider Demographics
NPI:1396918421
Name:TERRY KERN PHYSICAL THERAPY
Entity type:Organization
Organization Name:TERRY KERN PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:KERN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:505-761-0016
Mailing Address - Street 1:5971 JEFFERSON ST NE
Mailing Address - Street 2:STE 102
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3413
Mailing Address - Country:US
Mailing Address - Phone:505-761-0016
Mailing Address - Fax:505-761-0025
Practice Address - Street 1:5971 JEFFERSON ST NE
Practice Address - Street 2:STE 102
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3413
Practice Address - Country:US
Practice Address - Phone:505-761-0016
Practice Address - Fax:505-761-0025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM515174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM800521050OtherMEDICARE GROUP
NM174400000XMedicaid
NM348231002Medicare PIN