1134299555 NPI number — SOUTHWEST THERAPY & REHABILITATION

Table of content: (NPI 1134299555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134299555 NPI number — SOUTHWEST THERAPY & REHABILITATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST THERAPY & REHABILITATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STAR RIDSDALE
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134299555
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10900 TANZANITE DR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87114-1853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-239-9644
Provider Business Mailing Address Fax Number:
505-896-2958

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 21ST ST SE
Provider Second Line Business Practice Location Address:
SUITE #9
Provider Business Practice Location Address City Name:
RIO RANCHO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87124-4030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-239-9644
Provider Business Practice Location Address Fax Number:
505-896-2958
Provider Enumeration Date:
11/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RIDSDALE
Authorized Official First Name:
STAR
Authorized Official Middle Name:
AMBER
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-239-9644

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  1435 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1435 . This is a "STATE LIC. #" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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