Provider Demographics
NPI:1164038204
Name:ROCK PHYSICAL THERAPY RESILIENCE & TRAINING CENTER PC
Entity type:Organization
Organization Name:ROCK PHYSICAL THERAPY RESILIENCE & TRAINING CENTER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARLYN
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:505-278-8295
Mailing Address - Street 1:845 N SULLIVAN AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-7356
Mailing Address - Country:US
Mailing Address - Phone:505-278-8295
Mailing Address - Fax:505-436-2077
Practice Address - Street 1:845 SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-7356
Practice Address - Country:US
Practice Address - Phone:505-860-7812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-22
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy