MEDICARE: MESILLA VALLEY SLEEP LAB, LLC

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	261QS1200X	Sleep Disorder Diagnostic Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00NM007G71	OTHER	NM	BLUE CROSS BLUE SHIELD
2	95316	OTHER	NM	PRESBYTERIAN HEALTH PLAN

General Provider Information

NPI Number	:	1891808077
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MESILLA VALLEY SLEEP LAB, LLC

Provider Business Mailing Address
First Line	:	1155 COMMERCE DR STE G
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-8257
Country	:	US
Telephone Number	:	575-647-5337
Fax Number	:	575-647-5338

Provider Business Practice Location Address
First Line	:	1155 COMMERCE DR
Second Line	:	SUITE G
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-8257
Country	:	US
Telephone Number	:	575-532-7000
Fax Number	:	575-532-7006

Authorized Official
Title or Position	:	CLININCAL MANAGER
Name	:	MR. MARIO ZAMORA
Credential	:	RRT
Telephone Number	:	575-647-5337

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	01/13/2012

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