Provider Demographics
NPI:1700879590
Name:SMITH, TORY L (PT)
Entity Type:Individual
Prefix:MR
First Name:TORY
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2860
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88311-2860
Mailing Address - Country:US
Mailing Address - Phone:575-628-0503
Mailing Address - Fax:575-628-3073
Practice Address - Street 1:128 S CANYON ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-5733
Practice Address - Country:US
Practice Address - Phone:575-628-0503
Practice Address - Fax:575-628-3073
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2617225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00Q019OtherBLUE CROSS BLUE SHIELD
NM65579844Medicaid