Provider Demographics
NPI:1174567366
Name:PHYSICAL THERAPY CLINIC AT LA CUEVA
Entity type:Organization
Organization Name:PHYSICAL THERAPY CLINIC AT LA CUEVA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:LORIECIE
Authorized Official - Last Name:SIPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-344-4959
Mailing Address - Street 1:7920 CLAREMONT AVE NE
Mailing Address - Street 2:SUITE #3
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3712
Mailing Address - Country:US
Mailing Address - Phone:505-344-4959
Mailing Address - Fax:505-341-0426
Practice Address - Street 1:7920 CARMEL NE
Practice Address - Street 2:SUITE #3
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122
Practice Address - Country:US
Practice Address - Phone:505-344-4959
Practice Address - Fax:505-341-0426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)