Healthcare Provider Details

I. General information

NPI: 1659689347
Provider Name (Legal Business Name): TAOS SPORTS MEDICINE SERICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 CRESTVIEW DRIVE STE 1S
ANGEL FIRE NM
87710-0489
US

IV. Provider business mailing address

1398 WEIMER RD STE 203
TAOS NM
87571-6397
US

V. Phone/Fax

Practice location:
  • Phone: 575-377-1900
  • Fax: 575-377-2383
Mailing address:
  • Phone: 575-737-0304
  • Fax: 575-737-0383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number3072B1
License Number StateNM

VIII. Authorized Official

Name: JOCELYN LUCERO
Title or Position: OFFICE MANAGER
Credential:
Phone: 575-737-0304