Healthcare Provider Details

I. General information

NPI: 1417430406
Provider Name (Legal Business Name): LAZY RIVER THERAPY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 ROAD 3660
AZTEC NM
87410-9020
US

IV. Provider business mailing address

3 ROAD 3660
AZTEC NM
87410-9020
US

V. Phone/Fax

Practice location:
  • Phone: 505-402-9561
  • Fax:
Mailing address:
  • Phone: 505-402-9561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LINDA JEAN CALKINS
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential: MS/CCC
Phone: 505-402-9561