Provider Demographics
NPI:1427130137
Name:NEW MEXICO SPORTS & PT
Entity type:Organization
Organization Name:NEW MEXICO SPORTS & PT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:H
Authorized Official - Last Name:FAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:P T
Authorized Official - Phone:505-424-0131
Mailing Address - Street 1:2954 RODEO PARK DR W
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6351
Mailing Address - Country:US
Mailing Address - Phone:505-424-0131
Mailing Address - Fax:505-424-1299
Practice Address - Street 1:2954 RODEO PARK DR W
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6351
Practice Address - Country:US
Practice Address - Phone:505-424-0131
Practice Address - Fax:505-424-1299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6292261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN4536Medicaid
NM326508Medicare ID - Type Unspecified