Healthcare Provider Details

I. General information

NPI: 1104366533
Provider Name (Legal Business Name): LA LUZ THERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2017
Last Update Date: 11/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 SEVILLA AVE NW STE E
ALBUQUERQUE NM
87120-1853
US

IV. Provider business mailing address

1312 MESA WOOD PL NW
ALBUQUERQUE NM
87120-6565
US

V. Phone/Fax

Practice location:
  • Phone: 505-363-9582
  • Fax: 505-214-5137
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number4197
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number4196
License Number StateNM

VIII. Authorized Official

Name: MARISA RODDY
Title or Position: OWNER
Credential:
Phone: 505-363-9582