Healthcare Provider Details

I. General information

NPI: 1740739218
Provider Name (Legal Business Name): ELITE PROSTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 09/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5095 ELLISON ST NE SUITE B
ALBUQUERQUE NM
87109-4326
US

IV. Provider business mailing address

5095 ELLISON ST NE SUITE B
ALBUQUERQUE NM
87109-4326
US

V. Phone/Fax

Practice location:
  • Phone: 505-550-5290
  • Fax: 505-244-0708
Mailing address:
  • Phone: 505-550-5290
  • Fax: 505-244-0708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. KRISTEN M LOTT
Title or Position: CEO
Credential: NP
Phone: 505-244-0404