Healthcare Provider Details

I. General information

NPI: 1528276318
Provider Name (Legal Business Name): ALBUQUERQUE ORTHOTICS & PROSTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 ELLISON ST NE SUITE A
ALBUQUERQUE NM
87109-4331
US

IV. Provider business mailing address

PO BOX 90445
ALBUQUERQUE NM
87199-0445
US

V. Phone/Fax

Practice location:
  • Phone: 505-342-0333
  • Fax: 505-342-0336
Mailing address:
  • Phone: 505-342-0333
  • Fax: 505-342-0336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberFA0048723
License Number StateNM

VIII. Authorized Official

Name: MISS LISA M URSO
Title or Position: OWNER/PROSTHETIST ORTHOTIST
Credential: C.P.O.
Phone: 505-342-0333