Provider Demographics
NPI:1447268958
Name:SOUTHWEST PHYSICAL & SPORTS THERAPY, LTD
Entity type:Organization
Organization Name:SOUTHWEST PHYSICAL & SPORTS THERAPY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:STOKLOSA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:505-425-1117
Mailing Address - Street 1:2513 RIDGE RUNNER RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4972
Mailing Address - Country:US
Mailing Address - Phone:505-425-1117
Mailing Address - Fax:505-454-7810
Practice Address - Street 1:2513 RIDGE RUNNER RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4972
Practice Address - Country:US
Practice Address - Phone:505-425-1117
Practice Address - Fax:505-454-7810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6614225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ0423Medicaid
NM201079769OtherPRESBYTERIAN HEALTH
NM201079769OtherPRESBYTERIAN HEALTH