Provider Demographics
NPI:1801283452
Name:MOVEMENT AND PERFORMANCE OF NEW MEXICO
Entity type:Organization
Organization Name:MOVEMENT AND PERFORMANCE OF NEW MEXICO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BACA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:505-250-7049
Mailing Address - Street 1:1612 RIDGECREST DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-4437
Mailing Address - Country:US
Mailing Address - Phone:505-250-7049
Mailing Address - Fax:
Practice Address - Street 1:1612 RIDGECREST DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-4437
Practice Address - Country:US
Practice Address - Phone:505-250-7049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3533261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy