Healthcare Provider Details

I. General information

NPI: 1730262783
Provider Name (Legal Business Name): THERESA MARY ALONZO RT LAB TECH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 06/16/2008

III. Provider practice location address

12000 STONE LAKE ROAD
DULCE NM
87528-0187
US

IV. Provider business mailing address

PO BOX 187 12000 STONE LAKE ROAD
DULCE NM
87528-0187
US

V. Phone/Fax

Practice location:
  • Phone: 505-759-3291
  • Fax: 505-759-3532
Mailing address:
  • Phone: 505-759-3291
  • Fax: 505-759-3532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: