1023762424 NPI number — SACRED ROOTS PELVIC HEALTH AND PHYSICAL THERAPY LLC

Table of content: DR. LYNN W. ODNE D.D.S. (NPI 1689751869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023762424 NPI number — SACRED ROOTS PELVIC HEALTH AND PHYSICAL THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SACRED ROOTS PELVIC HEALTH AND PHYSICAL THERAPY LLC
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:
Provider Other Organization Name Type Code:
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:
1023762424
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9417 ADMIRAL LOWELL AVE NE
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:
87111-1201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-609-3487
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7013 4TH ST NW # E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS RANCHOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87107-6639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-609-3487
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/05/2022

Additional Information

Authorized Official

Authorized Official Last Name:
LINK
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
505-609-3487

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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