Provider Demographics
NPI:1669455994
Name:FOWLER ENTERPRISES INC
Entity type:Organization
Organization Name:FOWLER ENTERPRISES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:505-220-6949
Mailing Address - Street 1:PO BOX 1730
Mailing Address - Street 2:
Mailing Address - City:MORIARTY
Mailing Address - State:NM
Mailing Address - Zip Code:87035-1730
Mailing Address - Country:US
Mailing Address - Phone:505-832-4011
Mailing Address - Fax:505-832-0434
Practice Address - Street 1:2005B US ROUTE 66 WEST
Practice Address - Street 2:
Practice Address - City:MORIARTY
Practice Address - State:NM
Practice Address - Zip Code:87035
Practice Address - Country:US
Practice Address - Phone:505-832-4011
Practice Address - Fax:505-832-0434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1036225100000X
NM1037225100000X
NM1852225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM08028079Medicaid
NM=========Medicare PIN