Provider Demographics
NPI:1982777850
Name:ESPANOLA SPORTS MEDICINE, PA
Entity Type:Organization
Organization Name:ESPANOLA SPORTS MEDICINE, PA
Other - Org Name:ESPANOLA SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-334-1919
Mailing Address - Street 1:708 LA JOYA ST
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2511
Mailing Address - Country:US
Mailing Address - Phone:505-753-6550
Mailing Address - Fax:505-753-1219
Practice Address - Street 1:708 LA JOYA ST
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2511
Practice Address - Country:US
Practice Address - Phone:505-753-6550
Practice Address - Fax:505-753-1219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6628225100000X, 261QP2000X
261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR5803Medicaid
NM326550Medicare Oscar/Certification