MEDICARE: KASSANDRA LUCERO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1629632930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KASSANDRA LUCERO

Provider Business Mailing Address
First Line	:	PO BOX 35014
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87176-5014
Country	:	US
Telephone Number	:	505-554-3057
Fax Number	:

Provider Business Practice Location Address
First Line	:	4118 CENTRAL AVE SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87108-1177
Country	:	US
Telephone Number	:	505-554-3057
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2019
Last Update Date	:	04/23/2019

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Directions to “ KASSANDRA LUCERO ” Practice Location

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