Provider Demographics
NPI:1023166501
Name:S J KNACKSTEDT INC
Entity type:Organization
Organization Name:S J KNACKSTEDT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:KNACKSTEDT
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:505-265-3959
Mailing Address - Street 1:4516 ALTURA PLACE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5706
Mailing Address - Country:US
Mailing Address - Phone:505-265-3959
Mailing Address - Fax:505-262-9222
Practice Address - Street 1:4516 ALTURA PLACE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5706
Practice Address - Country:US
Practice Address - Phone:505-265-3959
Practice Address - Fax:505-262-9222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM144225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMD4185Medicaid