Healthcare Provider Details

I. General information

NPI: 1659504231
Provider Name (Legal Business Name): MARYLOU H LOZANO COMMUNITY SUPPORT SP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 06/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 WEST HICKORY ST
DEMING NM
88030
US

IV. Provider business mailing address

PO BOX 2267
SANTA FE NM
87504-2267
US

V. Phone/Fax

Practice location:
  • Phone: 575-546-2174
  • Fax: 575-544-4821
Mailing address:
  • Phone: 505-954-2303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: